Journal: J Am Soc Echocardiogr

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Abstract

Right Ventricular Outflow Tract Pacing Causes Intraventricular Dyssynchrony in Patients With Sick Sinus Syndrome: A Real-Time Three-Dimensional Echocardiographic Study.

Liu WH, Guo BF, Chen YL, Tsai TH, ... Chua S, Chen MC
Background: The optimal right ventricular pacing site remains controversial. The aim of this study was to assess how acute right ventricular outflow tract (RVOT) pacing affects global left ventricular function and intraventricular dyssynchrony of the left ventricle. Methods: Thirty-six patients with sick sinus syndrome and intact intrinsic atrioventricular conduction were enrolled. All patients underwent dual-chamber permanent pacemaker implantation, with the atrial lead placed in the right atrial appendage and the right ventricle lead positioned at the septal site of the RVOT. Chamber size, dyssynchrony index, myocardial performance index, and global left ventricular ejection fraction were determined using transthoracic two-dimensional echocardiography, tissue Doppler echocardiography, and real-time three-dimensional echocardiography. Results: RVOT pacing increased the myocardial performance index (0.42 +/- 0.21 with RVOT pacing vs 0.35 +/- 0.21 without RVOT pacing, P = .002) and decreased the global left ventricular ejection fraction on real-time 3-dimensional echocardiography (51.4 +/- 6.2% with RVOT pacing vs 55.9 +/- 7.1% without RVOT pacing, P = .001). Intraventricular dyssynchrony of the left ventricle induced by RVOT pacing was determined by increased septal-to-posterior wall motion delay (69.7 +/- 54.0 ms with RVOT pacing vs 22.8 +/- 22.3 ms without RVOT pacing, P < .0001), increased systolic and diastolic dyssynchrony by tissue Doppler echocardiography, and increased systolic dyssynchrony index when assessed using real-time three-dimensional echocardiography (5.56 +/- 1.74% with RVOT pacing vs 4.05 +/- 1.61% without RVOT pacing, P < .0001). Conclusion: Acute RVOT pacing adversely affects left ventricular function and increases intraventricular dyssynchrony in patients with sick sinus syndrome.

J Am Soc Echocardiogr: 19 Apr 2010; epub ahead of print
Liu WH, Guo BF, Chen YL, Tsai TH, ... Chua S, Chen MC
J Am Soc Echocardiogr: 19 Apr 2010; epub ahead of print | PMID: 20399607
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Changes in the Textural Characteristics of Intima-Media Complex in Young Patients with Familial Hypercholesterolemia: Implication for Visual Inspection on B-Mode Ultrasound.

Noto N, Okada T, Abe Y, Miyashita M, ... Sumitomo N, Mugishima H
Background: To test the hypothesis that textural changes in the carotid intima-media complex (IMC) on visual inspection by B-mode ultrasound are associated with early atherosclerotic involvement in patients with heterozygous familial hypercholesterolemia (FH). Methods: 55 patients (mean age 13.4 years) were categorized into three groups according to the degree of thickness in IMC (intima-media thickness [IMT]) (groups I-III) and 15 healthy controls within the same age range as the patients were assessed for first- and second-order statistics and visual scoring of textural changes in IMC (1, normal; 2, proximal interface disruption; 3, granulation). Results: There was no significant difference in first-order statistics among the four groups. As for second-order statistics, groups II (moderately increased IMT) and III (markedly increased IMT) had significantly higher entropy and lower angular second moment than group I (normal IMT) and control. Likewise, groups II and III received significantly higher visual scoring than group I. Visual scoring correlated with entropy (r = 0.57) and angular second moment (r = -0.50). Multiple regression analysis identified entropy (beta = 0.52) and visual scoring (beta = 0.42) as significant determinants of IMT. Conclusions: These findings demonstrate that higher visual scoring may indicate dishomogeneity of IMC, suggesting early medial infiltration. This seems to be a simple visual marker to more effectively identify high-risk young patients with FH.

J Am Soc Echocardiogr: 17 Feb 2011; epub ahead of print
Noto N, Okada T, Abe Y, Miyashita M, ... Sumitomo N, Mugishima H
J Am Soc Echocardiogr: 17 Feb 2011; epub ahead of print | PMID: 21324643
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Abstract

Echocardiographic Evaluation and Follow-Up of Cardiac and Aortic Indexes in Aviators Exposed to Acceleration Forces.

Assa A, Prokupetz A, Wand O, Harpaz D, Grossman A
Background: Military jet fighter pilots are routinely exposed to acceleration (+Gz) forces. This recurrent exposure may influence various cardiac parameters. A few previous studies have evaluated the impact of exposure to acceleration forces on cardiac morphology and function, but these studies were mostly based on small cohorts, and subjects did not undergo baseline echocardiographic examinations before +Gz exposure. Methods: Ninety-six jet fighter pilots with high +Gz exposure underwent echocardiographic evaluation before and 7 to 12 years after repeated +Gz exposure. Echocardiographic parameters were recorded using M-mode echocardiography and included left ventricular diameter at end-systole and end-diastole, interventricular septal thickness, thickness of the posterior wall, aortic root diameter and aortic valve opening, diameter of the left atrium, and left ventricular mass. Medical records of the subjects identified were evaluated for the development of adverse events. Results: The average age at the time of the initial echocardiographic examination was 19.2 years. All subjects were healthy, without cardiovascular risk factors, and had no prior exposure to acceleration forces. The average flying period on jet planes at the time of follow-up examination was 1,812 hours. The mean follow-up period was 9.13 years. All parameters evaluated by M-mode echocardiography were not significantly changed from the baseline examination. No adverse events occurred during the follow-up period. Conclusions: Exposure to acceleration forces has no significant impact on cardiac and aortic morphology.

J Am Soc Echocardiogr: 18 Jul 2011; epub ahead of print
Assa A, Prokupetz A, Wand O, Harpaz D, Grossman A
J Am Soc Echocardiogr: 18 Jul 2011; epub ahead of print | PMID: 21764554
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Abstract

Vena Contracta Width as a Predictor of Adverse Outcomes in Patients With Severe Isolated Tricuspid Regurgitation.

Yang WI, Shim CY, Kang MK, Chang HJ, ... Cho SY, Ha JW
Background: The clinical outcomes and predictors of outcomes in isolated tricuspid regurgitation (TR) are poorly defined. The aim of this study was to investigate the determinants of outcomes in severe isolated TR. Methods: Seventy-four patients (mean age, 63 ± 12 years; 34 men) with severe isolated TR who satisfied the criteria of (1) TR jet area > 30% of right atrial area or TR jet area > 10 cm(2) and (2) a plethora of inferior vena cava or systolic flow reversal of the hepatic vein were retrospectively analyzed. The primary end points were hospitalization for worsening heart failure, tricuspid valve (TV) surgery, and cardiovascular death. Results: During the median follow-up period of 53 months, 25 events occurred (three cardiovascular deaths, nine TV surgeries, and 13 hospitalizations for worsening heart failure). Univariate Cox analysis showed that younger age, female gender, larger effective regurgitant orifice, vena contracta width (VCW), and increased right atrial and right ventricular size were associated with cardiovascular events. Increased TV tethering distance and tethering area were also associated with cardiovascular events. In multivariate Cox regression analysis, larger VCW (hazard ratio, 1.72; 95% confidence interval, 1.15-2.57, P < 0.01) was an independent predictor of cardiovascular events. Compared with patients with VCW ≤ 7 mm, those with VCW > 7 mm had poorer long-term outcomes (adjusted hazard ratio, 19.9; P < .01). Increased VCW was also an independent predictor of cardiovascular death and TV surgery (hazard ratio, 1.2; 95% confidence interval, 1.00-1.45; P = .04). Conclusions: In severe isolated TR, VCW is a powerful independent predictor of adverse outcomes. Adverse outcomes were considerable for VCW > 7 mm, which suggests that quantification of TR by Doppler echocardiography is crucial for estimating prognosis. TV surgery might be considered for patients with severe isolated TR with VCW > 7 mm.

J Am Soc Echocardiogr: 08 Aug 2011; epub ahead of print
Yang WI, Shim CY, Kang MK, Chang HJ, ... Cho SY, Ha JW
J Am Soc Echocardiogr: 08 Aug 2011; epub ahead of print | PMID: 21820277
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Abstract

Value of estimated right ventricular filling pressure in predicting cardiac events in chronic pulmonary arterial hypertension.

Utsunomiya H, Nakatani S, Nishihira M, Kanzaki H, ... Kihara Y, Kitakaze M
Background: Right ventricular (RV) filling pressure can be estimated using tissue Doppler imaging (TDI) from the tricuspid lateral annulus, but few data are available on the usefulness of Doppler-derived RV filling pressure in predicting the prognosis of chronic pulmonary arterial hypertension (PAH). Methods: In 50 consecutive patients with PAH, TDI was performed within 24 hours of right-sided catheterization to measure early diastolic myocardial velocity at the tricuspid lateral annulus (E(a)) and early diastolic tricuspid inflow (E). The tricuspid E/E(a) ratio was calculated and compared with the invasive hemodynamic variables. Cardiac events were defined as cardiac death or rehospitalization due to RV failure. Results: Mean right atrial pressure (RAP) averaged 6 +/- 5 mm Hg (range, 1-25 mm Hg). E/E(a) correlated positively with mean RAP (r = 0.80, P < .001), irrespective of RV systolic function. We divided patients into group A with cardiac events (n = 19) and group B without events (n = 31) in a mean follow-up period of 14 months. Plasma brain natriuretic peptide level and E/E(a) were significantly higher in group A than in group B (349 +/- 310 pg/dL vs 129 +/- 136 pg/dL, P = .001; 7.0 +/- 3.2 vs 4.5 +/- 1.9, P = .004, respectively), whereas mean pulmonary artery pressure did not differ significantly. In a multivariate model, E/E(a) remained predictive for cardiac events (hazard ratio 1.227; 95% confidence interval, 1.042-1.444; P = .014). An E/E(a) cutoff value of 6.8 discriminated cases with cardiac events with a sensitivity of 42% and specificity of 97% (area under the curve 0.71). Conclusion: The tricuspid E/E(a) ratio provides a reliable estimation of RV filling pressure and predicts cardiac events in patients with PAH.

J Am Soc Echocardiogr: 30 Nov 2009; 22:1368-74
Utsunomiya H, Nakatani S, Nishihira M, Kanzaki H, ... Kihara Y, Kitakaze M
J Am Soc Echocardiogr: 30 Nov 2009; 22:1368-74 | PMID: 19944957
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Abstract

Myocardial Strain Assessment in Cystic Fibrosis.

Labombarda F, Pellissier A, Ellafi M, Creveuil C, ... Zalcman G, Saloux E
Background: The aim of this work was to evaluate myocardial strain analysis as a tool for the early detection of left ventricular functional changes in patients with cystic fibrosis. Methods: A total of 42 consecutive patients (mean age, 24 ± 7.5 years; 52% men) diagnosed with cystic fibrosis and referred for echocardiographic cardiac function assessment were prospectively enrolled. A group of healthy age-matched and gender-matched volunteers (n = 42) formed the reference population for echocardiographic comparisons. Results: Left ventricular ejection fraction was conserved in both groups but was significantly lower in the cystic fibrosis group. Cardiac function assessment using Doppler tissue imaging parameters revealed that both systolic and diastolic measurements differed between the two groups: mitral peak systolic and diastolic velocities, as well as septal and lateral wall strain rates, were decreased in patients with cystic fibrosis, as was longitudinal strain of both the septal and lateral walls. Conclusions: Using strain measurements, subclinical changes in left ventricular function were found in patients with cystic fibrosis. These parameters were correlated with the degree of pulmonary involvement severity. These findings have potentially significant clinical implications for the outcomes and follow-up of patients with cystic fibrosis, meriting further studies.

J Am Soc Echocardiogr: 18 Jul 2011; epub ahead of print
Labombarda F, Pellissier A, Ellafi M, Creveuil C, ... Zalcman G, Saloux E
J Am Soc Echocardiogr: 18 Jul 2011; epub ahead of print | PMID: 21764552
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Abstract

Clinical Validation of a Novel Speckle Tracking-Based Ejection Fraction Assessment Method.

Szulik M, Pappas CJ, Jurcut R, Magro M, ... Desmet W, Voigt JU
Background: The aim of this study was to determine the feasibility, accuracy, and reproducibility of a novel tracking-based echocardiographic ejection fraction (EF) assessment method in comparison with traditional methods based on magnetic resonance imaging and echocardiography. Methods: In a prospective assessment, apical echocardiographic grayscale image loops from 81 patients were read in random order by four experienced readers, blinded to any data of the cases. In three separate sessions, EFs were estimated using biplane tracking-based assessment and according to the modified Simpson\'s rule, as well as by visual interpretation in three apical views. Data were compared with a reference EF derived from echocardiography and magnetic resonance imaging. Results: On average, no significant difference was found between EF estimates of the different methods. Tracking-based EF assessments were possible in 90% of the patients. Tracking-based EF assessments showed slightly higher deviations from the reference EF than the modified Simpson\'s rule, while interobserver and intraobserver variability of tracking-based assessment were significantly better. Visual interpretation allowed the fastest EF assessment. Tracking-based EF assessment was approximately twice as fast as the modified Simpson\'s rule. Conclusions: Tracking-based EF assessment is feasible, has lower interobserver and intraobserver variability, and is faster than traditional echocardiographic EF quantification. Its minimal demand on user interaction makes it a favorable alternative to traditional echocardiographic approaches, with a particular clinical advantage when reliable follow-up measurements are needed.

J Am Soc Echocardiogr: 27 Jun 2011; epub ahead of print
Szulik M, Pappas CJ, Jurcut R, Magro M, ... Desmet W, Voigt JU
J Am Soc Echocardiogr: 27 Jun 2011; epub ahead of print | PMID: 21703823
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Abstract

Global Left Atrial Strain Correlates with CHADS(2) Risk Score in Patients with Atrial Fibrillation.

Saha SK, Anderson PL, Caracciolo G, Kiotsekoglou A, ... Mori N, Sengupta PP
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 < .001) and was a predictor of high risk for thromboembolism (CHADS(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.

J Am Soc Echocardiogr: 11 Apr 2011; epub ahead of print
Saha SK, Anderson PL, Caracciolo G, Kiotsekoglou A, ... Mori N, Sengupta PP
J Am Soc Echocardiogr: 11 Apr 2011; epub ahead of print | PMID: 21477990
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High-Resolution Echocardiographic Assessment of Infarct Size and Cardiac Function in Mice with Myocardial Infarction.

Yuan LJ, Wang T, Kahn ML, Ferrari VA
Background: The aim of this study was to develop a simple and reasonably precise echocardiographic method for the assessment of infarct size (IS) and cardiac dysfunction in mice after myocardial infarction. Methods: In vivo experiments were performed in C57BL/6J wild-type mice (n = 18) before and 48 hours after left anterior descending coronary artery ligation. Endocardial length-based echocardiographic IS was validated with that by three different histologic measurements. Left ventricular function was evaluated. Results: Excellent agreement was found between endocardial length-based echocardiographic measurement and angle-based histologic measurement of IS (r = 0.82, P < .001), and both methods strongly correlated with Tei index (r = 0.82, P < .001, and r = 0.74, P < .01) and fractional area change (r = -0.61, P < .05, and r = -0.81, P < .001). Conclusions: Endocardial length-based echocardiographic measurement proved to be a useful method for assessing myocardial IS and is applicable for biomedical and imaging research, and appears particularly promising in studies of left ventricular remodeling after myocardial infarction.

J Am Soc Echocardiogr: 03 Jan 2011; epub ahead of print
Yuan LJ, Wang T, Kahn ML, Ferrari VA
J Am Soc Echocardiogr: 03 Jan 2011; epub ahead of print | PMID: 21194885
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Abstract

Carotid Artery Stiffness and Diastolic Function in Subjects without Known Cardiovascular Disease.

Vriz O, Bossone E, Bettio M, Pavan D, Carerj S, Antonini-Canterin F
Background: The aim of this study was to investigate the relationship between carotid artery stiffness and diastolic function in a cohort of subjects without known cardiovascular risk factors and/or overt cardiovascular disease. Methods: Ninety-two healthy subjects underwent transthoracic echocardiographic Doppler and carotid echo-tracking studies. Measurements of local arterial stiffness were obtained at left common carotid artery level; stiffness parameter (β), and pressure-strain elasticity modulus (Ep) were calculated as well as intima-media thickness (IMT). Results: Stiffness parameter and Ep were correlated inversely with transmitral E wave (P < .01), E/A ratio, and septal Em (P < .01) and positively with A wave (P < .001). IMT was also associated with A wave, E/A ratio, Em, and Am but not with E wave. No association was found between IMT, β, and Ep. The correlation between arterial stiffness and left ventricular diastolic function remained significant after multivariate adjustment for age, sex, pulse pressure, and body mass index, but not with IMT. Conclusions: In healthy subjects, changes in central carotid stiffness are in line with left ventricular diastolic function independently of age, sex, pulse pressure, and body mass index.

J Am Soc Echocardiogr: 27 Jun 2011; epub ahead of print
Vriz O, Bossone E, Bettio M, Pavan D, Carerj S, Antonini-Canterin F
J Am Soc Echocardiogr: 27 Jun 2011; epub ahead of print | PMID: 21704497
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Advanced Cardiovascular Sonographer: a proposal of the American Society of Echocardiography Advanced Practice Sonographer Task Force.

Mitchell C, Miller FA, Bierig SM, Bremer ML, ... Sanchez L, Umland MM
Echocardiographic examinations require a well-trained and competent sonographer to obtain proper anatomic and physiologic data to establish an accurate diagnosis for clinical decision-making and patient management. Although the formal education and training of cardiovascular sonographers are evolving, many entry-level and staff sonographers may not have sufficient practical or clinical knowledge of the necessary components of the echocardiographic study for the individual patient\'s clinical presentation. In many clinical settings, echocardiograms are read after the patient has left the laboratory. Thus, there is a role for a sonographer who can practice at an advanced level in a cardiovascular ultrasound laboratory to ensure a proper echocardiographic examination is performed on every patient. In this setting, an Advanced Cardiovascular Sonographer (ACS) would be able to review the indication for and quality of the examination. If additional images were needed, the ACS would assist the sonographer in obtaining these images, which would lead to the performance of a complete and fully diagnostic examination before the patient had left the echocardiography laboratory. In clinical practice, the quality of the examinations performed would improve, advancements in echocardiographic methods could be taught and incorporated into daily practice, and patients would be better served. The present report is a proposal from the American Society of Echocardiography Advanced Practice Task Force that identifies the potential of cardiac sonographers to achieve the ACS level.

J Am Soc Echocardiogr: 30 Nov 2009; 22:1409-13
Mitchell C, Miller FA, Bierig SM, Bremer ML, ... Sanchez L, Umland MM
J Am Soc Echocardiogr: 30 Nov 2009; 22:1409-13 | PMID: 19944959
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Prediction of Heart Failure and Adverse Cardiovascular Events in Outpatients with Coronary Artery Disease Using Mitral E/A Ratio in Conjunction with E-Wave Deceleration Time: The Heart and Soul Study.

Mishra RK, Devereux RB, Cohen BE, Whooley MA, Schiller NB
Background: Deceleration time (DT) of early mitral inflow (E) is a marker of diastolic left ventricular (LV) chamber stiffness that is routinely measured during the quantitation of LV diastolic function with Doppler echocardiography. Shortened DT after myocardial infarction predicts worse cardiovascular outcome. Recent studies have shown that indexing DT to peak E-wave velocity (pE) augments its prognostic power in a population with a high prevalence of coronary risk factors and in patients with hypertension during antihypertensive treatment. However, in ambulatory subjects with stable coronary artery disease (CAD), it is not known whether DT predicts cardiovascular events and whether DT/pE improves its prognostic power. Methods: The ability of DT and DT/pE to predict heart failure (HF) hospitalizations and other major adverse cardiovascular events (MACEs) was studied prospectively in 926 ambulatory patients with stable CAD enrolled in the Heart and Soul Study. Unadjusted and multivariate-adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) were calculated for HF and other MACEs. Results: During a mean of 6.3 ± 2.0 years, there were 124 hospitalizations for HF and 198 other MACEs. Relative to participants with mitral E/A ratios in the normal range (0.75 < E/A < 1.5; n = 604), those with E/A ratios ≥ 1.5 (n = 107) had an increased risk for HF (HR, 2.54; 95% CI, 1.52-4.25, P < .001) but not for other MACEs (HR, 1.00; 95% CI, 0.60-1.68; P = 1.00), while those with E/A ratios ≤ 0.75 (n = 215) were not at increased risk for either outcome. Among patients with normal E/A ratios, lower DT/pE predicted HF (HR, 0.47; 95% CI, 0.23-0.97, P = .04 per point increase in ln{msec/[cm/sec]}), while DT alone did not. However, in this group with normal E/A ratios, neither DT/pE nor DT alone was predictive of other MACEs. In patients with E/A ratios ≤ 0.75 (n = 215) and those with E/A ratios ≥ 1.5 (n = 107), neither DT nor DT/pE predicted either end point. Conclusions: In ambulatory patients with stable CAD, restrictive filling (E/A ratio ≥ 1.5) is a powerful predictor of HF. Among those with normal mitral E/A ratios (0.75-1.5), only DT/pE predicts HF, while neither DT nor DT/pE predicts other MACEs. This suggests that mitral E/A ratio has significant prognostic value in patients with CAD, and in those with normal mitral E/A ratios, the normalization of DT to pE augments its prognostic power.

J Am Soc Echocardiogr: 18 Jul 2011; epub ahead of print
Mishra RK, Devereux RB, Cohen BE, Whooley MA, Schiller NB
J Am Soc Echocardiogr: 18 Jul 2011; epub ahead of print | PMID: 21764551
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Quantification of Mitral Regurgitation Using High Pulse Repetition Frequency Three-Dimensional Color Doppler.

Skaug TR, Hergum T, Amundsen BH, Skjærpe T, Torp H, Haugen BO
Background: The aim of this study was to validate a novel method of determining vena contracta area (VCA) and quantifying mitral regurgitation using multibeam high-pulse repetition frequency (HPRF) color Doppler. Methods: The Doppler signal was isolated from the regurgitant jet, and VCA was found by summing the Doppler power from multiple beams within the vena contracta region, where calibration was done with a reference beam. In 27 patients, regurgitant volume was calculated as the product of VCA and the velocity-time integral of the regurgitant jet, measured by continuous-wave Doppler, and compared with regurgitant volume measured by magnetic resonance imaging (MRI). Results: Spearman\'s rank correlation and the 95% limits of agreement between regurgitant volume measured by MRI and by multibeam HPRF color Doppler were r(s) = 0.82 and -3.0 +/- 26.2 mL, respectively. Conclusion: For moderate to severe mitral regurgitation, there was good agreement between MRI and multibeam HPRF color Doppler. Agreement was lower in mild regurgitation.

J Am Soc Echocardiogr: 25 Nov 2009; epub ahead of print
Skaug TR, Hergum T, Amundsen BH, Skjærpe T, Torp H, Haugen BO
J Am Soc Echocardiogr: 25 Nov 2009; epub ahead of print | PMID: 19914037
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Usefulness of aortic strain analysis by velocity vector imaging as a new echocardiographic measure of arterial stiffness.

Kim KH, Park JC, Yoon HJ, Yoon NS, ... Cho JG, Kang JC
Background: The role of velocity vector imaging (VVI) in evaluating arterial stiffness is not well known. We investigated the usefulness of vascular strain analysis by VVI in evaluating arterial stiffness. Methods: Heart-femoral and brachial-ankle pulse wave velocities (PWVs) were measured as standard parameters of arterial stiffness. Intima-media thickness (IMT), fractional shortening (FS), fractional area change (FAC) by two-dimensional (2D) and VVI methods, and peak circumferential strain (PS) of the descending thoracic aorta were measured as echocardiographic parameters of arterial stiffness and compared with PWV in 137 patients (53.8 +/- 13.4 years, 71 male). Results: Heart-femoral PWV was 9.0 +/- 2.4 m/s, and brachial-ankle PWV was 14.1 +/- 3.0 m/s. Aortic IMT was 0.97 +/- 0.23 mm, and FS was 10.0% +/- 4.0%. FAC was 10.9% +/- 5.2% by 2D tracing and 10.3% +/- 5.1% by the VVI method. PS was 5.4% +/- 3.0%. PS showed significant negative correlation with aortic IMT (r = -0.49, P < .01) and PWV (heart-femoral: r = -0.67, brachial-ankle: r = -0.75, P < .01). PS showed significant positive correlation with FS (r = 0.80, P < .01) and FAC (2D tracing: r = 0.86, VVI: r = 0.88, P < .01). Aortic IMT showed significant positive correlation with PWV (heart-femoral: r = 0.44, brachial-ankle: r = 0.60, P < .01) and negative correlation with FS (r = -0.61, P < .01) and FAC (2D tracing: r = -0.51, VVI: r = - 0.51, P < .01). FS showed significant negative correlation with PWV (heart-femoral: r = -0.54, brachial-ankle: r = -0.72, P < .01). FAC showed significant negative correlation with heart-femoral (2D method: r = -0.61, VVI: r = -0.62, P < .01) and brachial-ankle (2D tracing: r = -0.71, VVI: r = -0.73, P < .01) PWV. Conclusion: PS and FAC measured by VVI were significantly associated with parameters of arterial stiffness and thus can be used as new echocardiographic parameters of arterial stiffness.

J Am Soc Echocardiogr: 30 Nov 2009; 22:1382-8
Kim KH, Park JC, Yoon HJ, Yoon NS, ... Cho JG, Kang JC
J Am Soc Echocardiogr: 30 Nov 2009; 22:1382-8 | PMID: 19944958
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The Vena Contracta in Functional Tricuspid Regurgitation: A Real-Time Three-Dimensional Color Doppler Echocardiography Study.

Song JM, Jang MK, Choi YS, Kim YJ, ... Kang DH, Song JK
Background: The aims of this study were to evaluate the three-dimensional features and geometric determinants of the vena contracta (VC) in functional tricuspid regurgitation (TR) and to identify optimal width cutoff values for assessing functional TR severity. Methods: Real-time three-dimensional full-volume and color Doppler and two-dimensional Doppler echocardiographic images were obtained in 52 patients with various degrees of functional TR and in sinus rhythm. The tricuspid valve and right ventricle were geometrically analyzed. VC widths parallel to the septal-lateral and anteroposterior directions, VC area, and effective regurgitant orifice area (EROA) using proximal isovelocity surface area methods on real-time three dimensional color Doppler images were measured. Results: The septal-lateral VC width was 0.39 ± 0.37 cm smaller than the anteroposterior VC width (P < .001). VC widths and area were strongly correlated with EROA. The optimal cutoff values for the septal-lateral VC width, anteroposterior VC width, and VC area were 0.63 cm, 0.76 cm, and 0.37 cm(2), respectively, for moderate functional TR (EROA ≥0.2 cm(2)) and were 0.84 cm, 1.26 cm, and 0.57 cm(2), respectively, for severe functional TR (EROA ≥0.4 cm(2)). Multiple linear regression analyses showed that the septal leaflet tenting angle and septal-lateral annular diameter independently determined septal-lateral VC width, while the anterior leaflet tenting angle and anteroposterior annular diameter independently determined the anteroposterior VC width. Conclusions: Different VC width cutoff values should be applied according to the plane of view in functional TR, because the VC cross-sectional shape is ellipsoidal with a long anteroposterior direction. VC widths are determined by annular dilation and leaflet tenting in the corresponding directions.

J Am Soc Echocardiogr: 17 Feb 2011; epub ahead of print
Song JM, Jang MK, Choi YS, Kim YJ, ... Kang DH, Song JK
J Am Soc Echocardiogr: 17 Feb 2011; epub ahead of print | PMID: 21324644
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Early Hemodynamic Changes Versus Peak Values: What Is More Useful to Predict Occurrence of Dyspnea During Stress Echocardiography in Patients with Asymptomatic Mitral Stenosis?

Brochet E, Détaint D, Fondard O, Tazi-Mezalek A, ... Iung B, Vahanian A
Background: In asymptomatic mitral stenosis (MS), the usefulness of peak exercise Doppler echocardiography (DE) values is acknowledged, but the role of values recorded during the first stage of DE remains unclear. Methods: DE was analyzed in 48 asymptomatic patients with significant MS and revealed dyspnea in 22 patients (46%). Results: MS severity and rest and peak systolic pulmonary artery pressures (SPAPs) were not different between patients who did and did not develop dyspnea. Progressions of mean gradient and relative SPAP (ratio of SPAP/baseline SPAP) were significantly greater in patients who developed dyspnea compared with those who did not (P < .01), whereas no difference was observed for absolute SPAP progression (P = .28). Onset of dyspnea was associated with a high increase of relative SPAP (>90% at 60W, OR 2.31; CI, 1.2-4.8; P = .02) but not with the 60 mm Hg peak SPAP threshold (OR 1.3; CI, 0.7-43.1; P = .40). Conclusion: DE reveals symptoms in 46% of patients who are considered asymptomatic. Despite similar peak values, these patients have different hemodynamic parameters during the first level of exercise compared with patients remaining asymptomatic. This may lead to the integration of early hemodynamic changes in the evaluation of exercise tolerance.

J Am Soc Echocardiogr: 17 Feb 2011; epub ahead of print
Brochet E, Détaint D, Fondard O, Tazi-Mezalek A, ... Iung B, Vahanian A
J Am Soc Echocardiogr: 17 Feb 2011; epub ahead of print | PMID: 21324641
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Fetal Predictors of Urgent Balloon Atrial Septostomy in Neonates with Complete Transposition.

Punn R, Silverman NH
Background: In complete transposition of the great vessels, a restrictive patent foramen ovale leads to inadequate circulatory mixing and severe cyanosis. Urgent balloon atrial septostomy (BAS) improves mixing and bridges neonates to surgery. Several studies have determined risk factors in utero for poor postnatal outcomes in complete transposition of the great vessels, particularly a restrictive patent foramen ovale and ductus arteriosus. In addition to these risk factors, we studied two new features, a hypermobile septum and reverse diastolic patent ductus arteriosus shunt, to determine which patients will require an urgent BAS. Methods: We reviewed all 26 fetuses from 2001 to 2010 with complete transposition of the great vessels and closely examined the patent foramen ovale and septum primum for hypermobility, restriction, flat appearance, or redundancy. We defined hypermobility as a septum primum flap that oscillates between both atria. We also examined the ductus size and shunting pattern to evaluate whether these features contributed to urgent BAS. Results: In total, 14 of 26 fetuses required urgent BAS with improved cyanosis. Nine fetuses had an urgent BAS and a hypermobile septum, and 12 fetuses had no urgent BAS or hypermobile septum. Eight fetuses had an urgent BAS and a reverse diastolic patent ductus arteriosus, and 11 fetuses had no urgent BAS or reverse diastolic patent ductus arteriosus. A hypermobile septum and reverse diastolic patent ductus arteriosus had a significant association with urgent BAS (P < .01, sensitivity = 0.64 and 0.57, specificity = 1.0 and 0.92, positive predictive value = 1.0 and 0.89, negative predictive value = 0.71 and 0.65). No fetus had a restrictive patent foramen ovale/ductus arteriosus. Conclusion: A hypermobile septum and reverse diastolic patent ductus arteriosus are new prenatal findings to help predict the need for an urgent BAS postnatally in patients with complete transposition of the great vessels.

J Am Soc Echocardiogr: 17 Feb 2011; epub ahead of print
Punn R, Silverman NH
J Am Soc Echocardiogr: 17 Feb 2011; epub ahead of print | PMID: 21324642
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Abstract

Pericardial Rather Than Epicardial Fat Is a Cardiometabolic Risk Marker: An MRI vs Echo Study.

Sicari R, Sironi AM, Petz R, Frassi F, ... Picano E, Gastaldelli A
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.

J Am Soc Echocardiogr: 28 Jul 2011; epub ahead of print
Sicari R, Sironi AM, Petz R, Frassi F, ... Picano E, Gastaldelli A
J Am Soc Echocardiogr: 28 Jul 2011; epub ahead of print | PMID: 21795020
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Abstract

Usefulness of Pre-Procedure Cavotricuspid Isthmus Imaging by Modified Transthoracic Echocardiography for Predicting Outcome of Isthmus-Dependent Atrial Flutter Ablation.

Chen JY, Lin KH, Liou YM, Chang KC, Huang SK
Background: Anatomic characteristics of the cavotricuspid isthmus (CTI) have been reported to be related to the outcome of atrial flutter ablation therapy. However, preprocedural evaluation of CTI anatomy using modified transthoracic echocardiography to guide atrial flutter ablation has not been well described. Methods: Transthoracic echocardiography was prospectively performed before atrial flutter ablation in 42 patients with typical CTI-dependent atrial flutter. A modified apical long-axis view was designed to visualize and evaluate anatomic characteristics of the CTI and Eustachian ridge (ER). A prominent ER, extending from the inferior vena cava to the interatrial septum, is defined as an extensive ER. Results: Twenty-eight patients had straightforward ablation procedures, and 14 patients had difficult ablation procedures. Two patients with difficult procedures had unsuccessful ablation. Multivariate analysis (using CTI length, the presence of a pouch or recess, ER morphology, and significant tricuspid regurgitation as variables) showed that the presence of extensive ER was the only independent predictor of a difficult ablation procedure. The ablation time in patients with extensive ER (n = 13) was significantly longer than in those patients with nonextensive ER (n = 29) (1,638.4 ± 1,548.3 vs 413.8 ± 195.5 sec, P = .015). The incidence of difficulty in achieving bidirectional isthmus block was also higher in patients with extensive ER (10 of 13 vs four of 29, P < .001). Conclusion: Preprocedural transthoracic echocardiography using a modified apical long-axis view is useful to characterize the morphology of the CTI and the ER. An extensive ER is a strong predictor for difficult ablation of CTI-dependent atrial flutter.

J Am Soc Echocardiogr: 18 Jul 2011; epub ahead of print
Chen JY, Lin KH, Liou YM, Chang KC, Huang SK
J Am Soc Echocardiogr: 18 Jul 2011; epub ahead of print | PMID: 21764555
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Abstract

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

Fukuda Y, Tanaka H, Sugiyama D, Ryo K, ... Kawai H, Hirata KI
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 < .001). RV-free was also correlated with RV ejection fraction and RV end-systolic volume measured by cardiac magnetic resonance imaging and with 6-min walking distance (r = 0.60, r = 0.56, and r = 0.49, respectively, P < .05). Furthermore, the improvement in RV-free 5 ± 3 months after adding medical treatment was significantly correlated with that in 6-min walking distance (r = 0.68, P < .0001). Conclusions: RV-free has the potential to allow for noninvasive follow-up of patients with PH.

J Am Soc Echocardiogr: 21 Jul 2011; epub ahead of print
Fukuda Y, Tanaka H, Sugiyama D, Ryo K, ... Kawai H, Hirata KI
J Am Soc Echocardiogr: 21 Jul 2011; epub ahead of print | PMID: 21775102
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Abstract

The Prevalence of Echocardiographic Accretions on the Leads of Patients with Permanent Pacemakers.

Dundar C, Tigen K, Tanalp C, Izgi A, ... Oduncu V, Kirma C
Background: The aim of this study was to investigate the prevalence and clinical significance of echocardiographic "accretions" on intracardiac leads in patients with permanent pacemakers. Methods: Two hundred eleven patients with permanent cardiac pacemakers implanted between 1988 and 2005 were called by telephone to participate in this study. The cohort was identified retrospectively and followed prospectively after recruitment. Seventy-five patients who agreed to participate in the study were examined by using transthoracic and transesophageal echocardiography for the detection of pacemaker lead accretions. Blood samples were also obtained for aerobic and anaerobic cultures, high-sensitivity C-reactive protein, erythrocyte sedimentation rate, and complete blood count. The medical records of the patients were analyzed carefully, and patients were called by telephone to investigate mortality and clinical events after 5 years of follow-up. Results: The initial study group included 28 women and 47 men (mean age, 60 ± 15 years). At least one echocardiographic accretion on the pacemaker leads was identified in 16 subjects (21%) by transthoracic echocardiography and in 21 subjects (28%) by transesophageal echocardiography. All accretions were in the right atrial portion of the leads, whereas the ventricular segments of the leads were free of accretions. Patients with pacemaker lead accretions were significantly younger than those without accretions (P = .03). At 5-year follow-up, information could be obtained from 60 of the 75 patients. Among these 60 patients, 28 (46%) had died. There was no difference in mortality between patients who did and did not have lead accretions (P = .96). Patients who died during follow-up were older (P < .001), had shorter time intervals from pacemaker implantation to study enrollment (P = .002), had increased left atrial (P = .007) and right atrial (P = .04) sizes, and had higher pulmonary artery systolic pressures (P = .012) than those who were alive at 5 years. Logistic regression analysis revealed that age and pulmonary artery systolic pressure were independent predictors of mortality. Conclusions: Accretions on permanent pacemaker leads can be detected by both transthoracic and transesophageal echocardiography. Follow-up data did not demonstrate any effect of these accretions on 5-year survival.

J Am Soc Echocardiogr: 15 Apr 2011; epub ahead of print
Dundar C, Tigen K, Tanalp C, Izgi A, ... Oduncu V, Kirma C
J Am Soc Echocardiogr: 15 Apr 2011; epub ahead of print | PMID: 21493040
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Abstract

Left Ventricular Outflow Tract and Pulmonary Artery Stroke Distances Independently Predict Heart Failure Hospitalization and Mortality: The Heart and Soul Study.

Ristow B, Na B, Ali S, Whooley MA, Schiller NB
Background: Stroke distance of the left ventricular outflow tract (LVOT) or pulmonary artery (PA) is readily measurable by Doppler echocardiography. Stroke distance, calculated by the velocity time integral, expresses the average linear distance traveled by red blood cells during systole. We hypothesized that reduced stroke distance predicts heart failure (HF) hospitalization or mortality among ambulatory adults with stable coronary artery disease. Methods: We compared stroke distances by lowest quartile among 990 participants in the Heart and Soul Study. We calculated hazard ratios (HRs) for events adjusted for clinical and echocardiographic parameters. Results: At 5.9 ± 1.9-year follow-up, there were 154 HF hospitalizations and 271 all-cause deaths. Among 254 participants with LVOT stroke distance in the lowest quartile (≤18 cm), 24% developed HF hospitalization, compared with 10% of those with higher stroke distance (HR 2.7; CI, 2.0-3.8; P < .0001). This association remained after adjustment for multiple variables including medical history, heart rate, blood pressure, and left ventricular ejection fraction (HR 1.8; CI, 1.1-3.0; P = .02). Both LVOT stroke distance ≤18 cm and PA stroke distance ≤17 cm were independently associated with the combined end point of HF hospitalization and mortality (HR 1.4; CI, 1.1-1.9; P = .02). Conclusion: Reduced stroke distance predicts HF hospitalization and mortality independent of clinical and other echocardiographic parameters among ambulatory adults with coronary artery disease.

J Am Soc Echocardiogr: 17 Feb 2011; epub ahead of print
Ristow B, Na B, Ali S, Whooley MA, Schiller NB
J Am Soc Echocardiogr: 17 Feb 2011; epub ahead of print | PMID: 21324645
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Abstract

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

Morris DA, Gailani M, Vaz Pérez A, Blaschke F, ... Haverkamp W, Ozcelik C
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 < .0001). On multiple regression analysis, LV global longitudinal systolic strain and diastolic strain rate were the most important independent predictors of LA longitudinal systolic and diastolic function, in contrast to noninvasive LV filling pressures (i.e., mitral E/e\' average septal-lateral ratio), which were modestly related to LA longitudinal systolic and diastolic function. Furthermore, in patients with HFNEF, the subendocardial function of both the left atrium and the left ventricle was significantly impaired in high proportions. In that regard, in patients with HFNEF, the rate of LA longitudinal systolic and diastolic dysfunction was 65.5% and 28.5%, whereas the prevalence of LV longitudinal systolic and diastolic dysfunction was 81.5% and 58%, respectively. In addition, patients with both systolic and diastolic longitudinal dysfunction of the left atrium presented worse NYHA functional class as compared with those with normal LA longitudinal function. 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.

J Am Soc Echocardiogr: 04 Apr 2011; epub ahead of print
Morris DA, Gailani M, Vaz Pérez A, Blaschke F, ... Haverkamp W, Ozcelik C
J Am Soc Echocardiogr: 04 Apr 2011; epub ahead of print | PMID: 21458230
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Relationship between Cognitive Impairment and Echocardiographic Parameters: A Review.

Arangalage D, Ederhy S, Dufour L, Joffre J, ... Tzourio C, Cohen A
With >24 million people affected worldwide, dementia is one of the main public health challenges modern medicine has to face. The path leading to dementia is often long, with a wide spectrum of clinical presentations, and preceded by a long preclinical phase. Previous studies have demonstrated that clinical strokes and covert vascular lesions of the brain contribute to the risk for developing dementia. Although it is not yet known whether preventing such lesions reduces the risk for dementia, it is likely that starting preventive measures early in the course of the disease may be beneficial. Echocardiography is a widely available, relatively inexpensive, noninvasive imaging modality whereby morphologically or hemodynamically derived parameters may be integrated easily into a risk assessment model for dementia. The aim of this review is to analyze the information that has accumulated over the past two decades on the prognostic value of echocardiographic factors in cognitive impairment. The associations between cognitive impairment and echocardiographic parameters, including left ventricular systolic and diastolic indices, left atrial morphologic parameters, cardiac output, left ventricular mass, and aortic root diameter, have previously been reported. In the light of these studies, it appears that echocardiography may help further improve currently used risk assessment models by allowing detection of subclinical cardiac abnormalities associated with future cognitive impairment. However, many limitations, including methodologic heterogeneity and the observational designs of these studies, restrict the scope of these results. Further prospective studies are required before integrating echocardiography into a preventive strategy.

J Am Soc Echocardiogr: 22 Dec 2014; epub ahead of print
Arangalage D, Ederhy S, Dufour L, Joffre J, ... Tzourio C, Cohen A
J Am Soc Echocardiogr: 22 Dec 2014; epub ahead of print | PMID: 25532969
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Abstract

A Longitudinal Study of Carotid Plaque and Risk of Ischemic Cardiovascular Disease in the Chinese Population.

Xie W, Wu Y, Wang W, Zhao D, ... Shi P, Huo Y
Background: The aim of this study was to investigate the role of carotid plaque in predicting ischemic cardiovascular risk, which has been intensively reported in Western populations but not yet in the Chinese population, in which the cardiovascular disease profile is significantly different. Methods: Cox proportional-hazards regression was used to analyze associations between the presence of carotid plaque and the number of segments of carotid arteries with plaque (total plaque score) and the risk for subsequent ischemic cardiovascular disease (ICVD) events, including ischemic stroke and coronary heart disease, in 3,258 Chinese men and women aged 38 to 79 years at baseline. During 5 years of follow-up, 137 ICVD events were identified. Results: The person-year incidence was 10.6 per 1,000 for ICVD, 6.7 per 1,000 for ischemic stroke, and 4.4 per 1,000 for coronary heart disease. After adjustment for conventional cardiovascular risk factors, the risk for ICVD was significantly associated with the presence of carotid plaque (hazard ratio, 1.49; 95% confidence interval [CI], 1.05-2.14) and total plaque score (hazard ratio per 1-score increase, 1.25; 95% CI, 1.04-1.50). Further analysis showed that the multivariate-adjusted hazard ratio of ICVD associated with plaque in common carotid arteries was 1.90 (95% CI, 1.15-3.13) and that with plaque in bifurcations was 1.26 (95% CI, 0.86-1.85). The results of separate analyses for ischemic stroke and coronary heart disease paralleled those for ICVD. The addition of total plaque score to the risk prediction model resulted in a significant improvement in risk estimation when measured by net reclassification improvement index. Conclusions: Carotid plaque adds significant additional information for predicting the risk for ICVD events in the Chinese population.

J Am Soc Echocardiogr: 28 Mar 2011; epub ahead of print
Xie W, Wu Y, Wang W, Zhao D, ... Shi P, Huo Y
J Am Soc Echocardiogr: 28 Mar 2011; epub ahead of print | PMID: 21440416
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Abstract

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

Marcus KA, Mavinkurve-Groothuis AM, Barends M, van Dijk A, ... de Korte C, Kapusta L
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 < .001) between global peak systolic strain parameters and age. Global peak systolic strain values were lowest in the youngest and oldest age groups. 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.

J Am Soc Echocardiogr: 11 Mar 2011; epub ahead of print
Marcus KA, Mavinkurve-Groothuis AM, Barends M, van Dijk A, ... de Korte C, Kapusta L
J Am Soc Echocardiogr: 11 Mar 2011; epub ahead of print | PMID: 21392941
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Peak Systolic Mitral Annulus Velocity Reflects the Status of Ventricular-Arterial Coupling-Theoretical and Experimental Analyses.

Uemura K, Kawada T, Sunagawa K, Sugimachi M
Background: Peak systolic mitral annular velocity (S(m)) measured by tissue Doppler echocardiography has been recognized as an independent predictor of mortality in patients with heart failure and in the general population. However, the mechanical determinants of S(m) remain poorly defined. Methods: A theoretical model of S(m) was derived, which indicates that S(m) is affected positively by left ventricular (LV) contractility and preload and inversely by LV afterload and ejection time (EJT). In 16 anesthetized dogs, S(m), LV volume, and LV pressure were measured using sonomicrometry and catheter-tip micromanometry. LV contractility, preload, and afterload were indexed by the end-systolic pressure/volume ratio (E(es)\'), end-diastolic volume (V(ed)), and effective arterial elastance (E(a)), respectively. LV contractility, loading conditions, and heart rate were varied over wide ranges, and a total of 76 data sets were obtained for S(m) (1.2-9.1 cm/sec), E(es)\' (1.5-17.6 mm Hg/mL), V(ed) (11-99 mL), E(a) (3.6-58.4 mm Hg/mL), EJT (100-246 msec), heart rate (66-192 beats/min), and the ventricular-arterial coupling ratio (E(es)\'/E(a); 0.2-3.0). Results: The theoretical model accurately predicted S(m) (R(2) = 0.79, P < .0001). By univariate analysis, S(m) was correlated significantly with E(es)\' (R(2) = 0.64, P < .0001) and with the reciprocal of E(a) (R(2) = 0.49, P < .01). V(ed) and EJT did not affect S(m). E(es)\'/E(a) was correlated strongly with S(m) (R(2) = 0.73, P < .0001). E(es)\' and the reciprocal of E(a) were not correlated with each other. Conclusions: LV contractility and afterload independently determine S(m). The effects of LV preload and EJT on S(m) might be small, even though they are theoretically associated with S(m). S(m) strongly reflects the status of ventricular-arterial coupling.

J Am Soc Echocardiogr: 24 Feb 2011; epub ahead of print
Uemura K, Kawada T, Sunagawa K, Sugimachi M
J Am Soc Echocardiogr: 24 Feb 2011; epub ahead of print | PMID: 21345650
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Imaging the Atrial Septum Using Real-Time Three-Dimensional Transesophageal Echocardiography: Technical Tips, Normal Anatomy, and Its Role in Transseptal Puncture.

Faletra FF, Nucifora G, Ho SY
Extraordinary advances in technology have made possible percutaneous catheter-based treatment of a wide spectrum of specific pediatric and adult "structural" heart diseases. Many of these percutaneous interventional procedures require access to the left heart via transseptal catheterization. Being able to see the anatomy can be a considerable advantage. However, septal anatomy is more complex than perceived at first sight. The true interatrial septum comprises a valvelike flap forming the floor of the fossa ovalis. On the right atrial aspect, the muscular rim surrounding the fossa is an infolding of the atrial wall. Hence, the target area for safe crossing, without exiting the heart, is the fossa floor and its immediate margin of the rim. Real-time (RT) three-dimensional (3D) transesophageal echocardiography is a recently developed technique that provides 3D images of the heart. Because of lack of interference from bone and lung and the closer proximity of the transducer to the posterior structures of the heart, this technique provides 3D RT images of atrial structures of unprecedented quality. In this review, the authors describe two key areas: a step-by-step approach for acquiring and processing RT 3D transesophageal echocardiographic images of the interatrial septum and, second, septal anatomy as it is visualized by RT 3D transesophageal echocardiography. To demonstrate their consistency with actual anatomy, several RT 3D transesophageal echocardiographic images are matched to equivalent anatomic specimens.

J Am Soc Echocardiogr: 11 Mar 2011; epub ahead of print
Faletra FF, Nucifora G, Ho SY
J Am Soc Echocardiogr: 11 Mar 2011; epub ahead of print | PMID: 21392940
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Abstract

A Novel Bilayer Approach to Ventricular Septal Deformation Analysis by Speckle Tracking Imaging in Children With Right Ventricular Overload.

Hayabuchi Y, Sakata M, Ohnishi T, Kagami S
Background: The aim of this study was to evaluate functional differences between the left and right sides of the ventricular septum in children with right ventricular overload. Methods: Radial, longitudinal, and circumferential strain on both sides of the ventricular septum were compared using speckle-tracking echocardiography in patients with preoperative atrial septal defects (n = 22), postoperative tetralogy of Fallot (n = 23) and age-matched normal controls (n = 44). The duration between peak strain of the left and right ventricular septum (TLt-Rt) was also evaluated. Results: Radial and circumferential strain in the control group were significantly higher on the left than the right ventricular septum (41.3 ± 12.8% vs 22.6 ± 6.8% and -28.0 ± 5.4% vs -22.5 ± 4.8%, respectively; P < .0001 for both), whereas longitudinal strain did not significantly differ (-22.0 ± 4.9% and -20.7 ± 5.2%, respectively). TLt-Rt was 52.9 ± 35.6, 33.4 ± 29.0, and 38.7 ± 31.0 msec for radial, longitudinal, and circumferential strain, respectively. Longitudinal and circumferential strain on both sides were significantly increased in patients with atrial septal defects compared with controls (P < .05), although radial strain was similar on both sides. Radial strain on the right side was significantly increased in patients with tetralogy of Fallot compared with controls (P < .05), whereas that on the left side was significantly reduced (P < .001). Longitudinal strain on both sides was significantly decreased (P < .01 and P < .001 for the left and right sides, respectively). In addition, TLt-Rt in patients with tetralogy of Fallot was significantly increased with radial and circumferential deformation (P < .05 for both). Conclusions: Deformation of both sides of the ventricular septum functionally differed. Bilayer analysis of the ventricular septum can help in the evaluation of right ventricular performance under volume and pressure overload.

J Am Soc Echocardiogr: 08 Aug 2011; epub ahead of print
Hayabuchi Y, Sakata M, Ohnishi T, Kagami S
J Am Soc Echocardiogr: 08 Aug 2011; epub ahead of print | PMID: 21820866
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Echocardiographic and Fluoroscopic Fusion Imaging for Procedural Guidance: An Overview and Early Clinical Experience.

Thaden JJ, Sanon S, Geske JB, Eleid MF, ... Rihal CS, Bruce CJ
There has been significant growth in the volume and complexity of percutaneous structural heart procedures in the past decade. Increasing procedural complexity and accompanying reliance on multimodality imaging have fueled the development of fusion imaging to facilitate procedural guidance. The first clinically available system capable of echocardiographic and fluoroscopic fusion for real-time guidance of structural heart procedures was approved by the US Food and Drug Administration in 2012. Echocardiographic-fluoroscopic fusion imaging combines the precise catheter and device visualization of fluoroscopy with the soft tissue anatomy and color flow Doppler information afforded by echocardiography in a single image. This allows the interventionalist to perform precise catheter manipulations under fluoroscopy guidance while visualizing critical tissue anatomy provided by echocardiography. However, there are few data available addressing this technology\'s strengths and limitations in routine clinical practice. The authors provide a critical review of currently available echocardiographic-fluoroscopic fusion imaging for guidance of structural heart interventions to highlight its strengths, limitations, and potential clinical applications and to guide further research into value of this emerging technology.

J Am Soc Echocardiogr: 28 Mar 2016; epub ahead of print
Thaden JJ, Sanon S, Geske JB, Eleid MF, ... Rihal CS, Bruce CJ
J Am Soc Echocardiogr: 28 Mar 2016; epub ahead of print | PMID: 27021355
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Abstract

Restrictive versus Nonrestrictive Physiology Following Repair of Tetralogy of Fallot: Is There a Difference?

Samyn MM, Kwon EN, Gorentz JS, Yan K, ... Frommelt PC, Tweddell JS
Background: Long-term outcome in repaired tetralogy of Fallot (TOF) is related to chronic pulmonary insufficiency (PI), right ventricular (RV) dilation, and deterioration of RV function. The aim of this study was to characterize clinical differences between restrictive and nonrestrictive RV physiology in young patients with repaired TOF. Methods: Patients were prospectively enrolled from February 2008 to August 2009. Each had a clinic visit, brain natriuretic peptide assessment, exercise test, cardiac magnetic resonance study, and echocardiographic examination with assessment of regional myocardial mechanics. Consistent antegrade diastolic pulmonary arterial flow with atrial contraction identified restrictive RV physiology. Results: Twenty-nine patients (median age, 12 years; range, 8-33 years; nine male patients) were studied. Twelve had restrictive RV physiology. The median time since initial TOF repair was 12 years (range, 5-27 years). Restrictive physiology appeared more prevalent after transannular patch repair and was not influenced by other demographic features. The restrictive group had more PI (46% vs 28%, P = .002), larger RV end-diastolic volumes (128 vs 98 mL/m(2), P = .046), but similar ejection fractions, brain natriuretic peptide levels, New York Heart Association classes, and exercise capacity. RV basal and mid free wall peak diastolic strain rate differed between groups, negatively correlating with exercise time and positively correlating with PI in patients with restrictive physiology. Conclusions: Restrictive RV physiology correlates with a larger right ventricle and increased PI after TOF repair but does not negatively affect other markers of myocardial health. Diastolic regional RV myocardial mechanics, particularly diastolic velocity and peak diastolic strain rate, differ for postoperative TOF patients with restrictive and nonrestrictive RV physiology; longitudinal study is necessary to understand the relationship of regional myocardial mechanics and patients\' clinical status.

J Am Soc Echocardiogr: 28 Apr 2013; epub ahead of print
Samyn MM, Kwon EN, Gorentz JS, Yan K, ... Frommelt PC, Tweddell JS
J Am Soc Echocardiogr: 28 Apr 2013; epub ahead of print | PMID: 23623591
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Frequent Periodic Leg Movement during Sleep Is Associated with Left Ventricular Hypertrophy and Adverse Cardiovascular Outcomes.

Mirza M, Shen WK, Sofi A, Jahangir A, ... Tajik AJ, Jahangir A
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 < .001). Advanced age, female sex, and apnea-hypopnea index were other predictors of LVH. Patients with periodic movement index > 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.

J Am Soc Echocardiogr: 28 Apr 2013; epub ahead of print
Mirza M, Shen WK, Sofi A, Jahangir A, ... Tajik AJ, Jahangir A
J Am Soc Echocardiogr: 28 Apr 2013; epub ahead of print | PMID: 23622883
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Abstract

Abnormalities in Cardiac Structure and Function in Adults with Sickle Cell Disease are not Associated with Pulmonary Hypertension.

Knight-Perry JE, de Las Fuentes L, Waggoner AD, Hoffmann RG, ... Dávila-Román VG, Field JJ
Background: In sickle cell disease (SCD), pulmonary hypertension (assessed by tricuspid regurgitant jet [TRJ] velocity ≥ 2.5 m/sec) is associated with increased mortality. The relationships among TRJ velocity and left ventricular (LV) and right ventricular (RV) systolic and diastolic function (i.e., relaxation and compliance) have not been well characterized in SCD. Methods: A prospective study was conducted in 53 ambulatory adults with SCD (mean age, 34 years; range, 21-65 years) and 33 African American controls to define the relationship between LV and RV function and TRJ velocity using echocardiography. Results: Subjects with SCD had larger left and right atrial volumes and increased LV mass compared with controls. When patients with SCD were compared with controls, LV and RV relaxation (i.e., E\') were similar. Among subjects with SCD, pulmonary hypertension (TRJ ≥ 2.5 m/sec) was present in 40%. Higher TRJ velocity was correlated with larger left atrial volumes in patients with SCD. Additionally, some measures of LV (peak A, lateral and septal annular E/E\' ratio) and RV (tricuspid valve E/E\' ratio) compliance were correlated with TRJ velocity. No other measures of LV and RV systolic function or LV diastolic function (i.e., relaxation and compliance) were associated with TRJ velocity. Conclusions: Ambulatory adults with SCD exhibited structural (i.e., LV and RV chamber enlargement) and functional (i.e., higher surrogate measures of LV and RV filling pressure) abnormalities compared with the control group. In subjects with SCD, few abnormalities of LV and RV structure and function were associated with TRJ velocity.

J Am Soc Echocardiogr: 29 Aug 2011; epub ahead of print
Knight-Perry JE, de Las Fuentes L, Waggoner AD, Hoffmann RG, ... Dávila-Román VG, Field JJ
J Am Soc Echocardiogr: 29 Aug 2011; epub ahead of print | PMID: 21873028
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Abstract

The Incremental Value of Right Ventricular Indices for Predicting Response to Cardiac Resynchronization Therapy.

Szulik M, Streb W, Lenarczyk R, Stabryła-Deska J, ... Kalarus Z, Kukulski T
Background: Right ventricular (RV) dysfunction in chronic heart failure (HF) is associated with poor prognosis. Cardiac resynchronization therapy (CRT) is an established method of improving prognosis in HF. However, the majority of known indices predictive of response to CRT are based on left ventricular (LV) assessment. The authors hypothesized that baseline RV function and tissue Doppler-derived dyssynchrony may have incremental value over LV dyssynchrony measures for predicting CRT response. Methods: In this retrospective study, echocardiographic examinations were performed in 90 patients before pacemaker implantation and up to 18 months afterward. CRT results were evaluated using clinical criteria (death, hospitalization for decompensation, change in New York Heart Association class ≥1, and 10% decreases in both peak ventilatory oxygen uptake and 6-min walking distance) and reverse remodeling (>15% reduction in LV end-systolic volume). Results: Baseline RV dyssynchrony during isovolumic contraction of 26 msec facilitated the segregation of responders from nonresponders with 85% sensitivity and 100% specificity, as well as synchrony in peak deformation of 54 msec, with 89% sensitivity and 67% specificity. The minor axis of the RV inflow tract predicted reverse remodeling after CRT with sensitivity of 73% and specificity of 58% with a cutoff value of 35 mm. According to the clinical criteria, LV indices (end-diastolic and end-systolic volumes) and interventricular delay gave an overall R(2) value of 0.20 (86.2% correctly classified patients; area under the curve, 0.80). The addition of RV dyssynchrony parameters (measured in peak strain and isovolumic contraction peak velocities) significantly increased the power of the model (R(2) = 0.86; 100% of patients correctly classified; area under the curve, 1; P for change in R(2) < .0001). Conclusions: The value of baseline RV function analysis is incremental to LV indices for the prediction of clinical response to CRT but not reverse remodeling. RV synchronous longitudinal deformation and RV dyssynchronous isovolumic velocity are independent predictors of clinical response to CRT.

J Am Soc Echocardiogr: 23 Dec 2010; epub ahead of print
Szulik M, Streb W, Lenarczyk R, Stabryła-Deska J, ... Kalarus Z, Kukulski T
J Am Soc Echocardiogr: 23 Dec 2010; epub ahead of print | PMID: 21177070
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Abstract

Noninvasive Evaluation of Right Atrial Pressure.

Beigel R, Cercek B, Luo H, Siegel RJ
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.

J Am Soc Echocardiogr: 16 Jul 2013; epub ahead of print
Beigel R, Cercek B, Luo H, Siegel RJ
J Am Soc Echocardiogr: 16 Jul 2013; epub ahead of print | PMID: 23860098
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Abstract

Age- and Gender-Dependency of Left Ventricular Geometry Assessed with Real-Time Three-Dimensional Transthoracic Echocardiography.

Kaku K, Takeuchi M, Otani K, Sugeng L, ... Mor-Avi V, Lang RM
Background: Aging and gender may affect left ventricular (LV) mechanics. The aim of this study was to determine the age and gender dependency of LV mechanical indices obtained from real-time three-dimensional echocardiography (RT3DE). Methods: RT3DE was performed in 280 healthy subjects (age range, 1-88 years; 137 men). From full-volume data sets, LV endocardial and epicardial borders were semiautomatically traced using quantitative software. LV volumes and corresponding long-axis diameter were measured throughout the cardiac cycle. Sphericity index was defined as the ratio of LV volume and spherical volume, calculated as 4/3 × π × (long-axis diameter/2)(3). LV mass was calculated as (LV epicardial volume - LV endocardial volume) × 1.05. The ratio of LV mass to LV volume was also calculated. Results: The mean value of LV ejection fraction did not change with age. However, LV volumes, mass, sphericity index, and LV mass/volume ratio were altered by age: (1) sphericity index was highest in the first decade of age and then declined until the fifth decade, (2) LV mass/volume ratio significantly increased in older age, and (3) LV mass/volume ratio was significantly higher in aged women compared with age-matched men. Conclusions: Age has heterogeneous effects on LV shape and LV mass/volume ratio, potentially due to the growing process of myocardial fibers and the surrounding architecture in the younger population, as well as the aging process, with an increase in vascular stiffness and a loss of myocytes in older populations. Higher LV mass/volume ratios in older women might be a contributor to the preferential development of diastolic heart failure in this population.

J Am Soc Echocardiogr: 24 Feb 2011; epub ahead of print
Kaku K, Takeuchi M, Otani K, Sugeng L, ... Mor-Avi V, Lang RM
J Am Soc Echocardiogr: 24 Feb 2011; epub ahead of print | PMID: 21345649
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Abstract

Factors Determining Outcomes of Aortic Valve Surgery in Patients with Aortic Regurgitation Due to Behçet\'s Disease: Impact of Preoperative Echocardiographic Features.

Song JK, Kim MJ, Kim DH, Song JM, ... Lee SK, Yoo B
Background: Paravalvular leakage after open heart surgery is notoriously common in patients with aortic regurgitation (AR) due to Behçet\'s disease. The aim of this study was to test whether initial echocardiographic findings are useful to predict recurrent AR. Methods: Lesion severity on preoperative echocardiography was scored for redundant aortic valve cusp (0-2 points), aortic pseudoaneurysm (0-2 points), and dissection of the adjacent interventricular septum (0-2 points) in 22 patients with severe AR due to Behçet\'s disease (13 men; mean age, 42.4 ± 11.5 years), which was confirmed by histologic examination after open heart surgery. Results: Recurrent AR developed in 13 patients at a median of 12.6 months (range, 2.4-70.3 months) after the first operation, and 10, four, and one patient underwent second, third, and fourth surgery, respectively, to control recurrent AR; three patients died. Those patients with recurrent AR had a significantly higher incidence of repeat surgery or death (84.6% [11 of 13] vs 0%, P = .015). Multivariate analysis showed that perioperative immunotherapy (hazard ratio, 0.002; 95% confidence interval, 0.001-0.1761; P = .006) and total echocardiographic score (hazard ratio, 2.843; 95% confidence interval, 1.350-5.991; P = .006) were independent factors associated with recurrent AR. The 1-year, 3-year, and 5-year AR-free survival rates were 73 ± 10%, 46 ± 12%, and 39 ± 12%. The optimal cutoff value for total echocardiographic score was 3.0, and the 5-year AR-free survival rates were significantly lower in patients with scores ≥ 3 (20 ± 13% vs 50 ± 19%, P = .022). Conclusions: This retrospective study confirms that initial echocardiographic features can provide useful prognostic information in patients with AR due to Behçet\'s disease.

J Am Soc Echocardiogr: 28 Jul 2011; epub ahead of print
Song JK, Kim MJ, Kim DH, Song JM, ... Lee SK, Yoo B
J Am Soc Echocardiogr: 28 Jul 2011; epub ahead of print | PMID: 21795019
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Abstract

Different Patterns of Adaptation of the Right Ventricle to Pressure Overload: A Comparison between Pulmonary Hypertension and Pulmonary Stenosis.

Jurcut R, Giusca S, Ticulescu R, Popa E, ... Voigt JU, Ginghina C
Background: The study was designed to compare RV morphological and functional parameters derived from conventional and myocardial deformation echocardiography in two instances of right heart pressure overload: pulmonary arterial hypertension (PAH) and pulmonary stenosis (PS). Methods: Sixty-two individuals were included: 22 patients with pulmonary arterial hypertension (PAH), 19 patients with PS and 21 healthy individuals who served as a control group. All patients had clinical evaluation with 6-minute walking test, standard and two-dimensional strain echocardiography and B-type natriuretic peptide evaluation. Results: At similar levels of pressure overload (RV systolic pressure, 88.2 ± 31.5 vs 73.4 ± 34.9 mm Hg; P = NS) the right ventricles of patients with PS were less dilated (RV end-diastolic diameter, 31.7 ± 3.7 vs 43.7 ± 10.5 mm; P < .001) and performed significantly better than those of patients with PAH (RV strain, -27.4 ± 5.8% vs 16.2 ± 7.9%; RV fractional area change, 51.1 ± 9.2% vs 29.1 ± 11.3%; P < .001). Although some of the RV functional parameters were comparable with those in healthy individuals, strain rate showed lower values, suggesting subclinical longitudinal dysfunction in patients with PS. Myocardial stress biomarkers were correlated with RV systolic pressure only in patients with PAH (r = 0.64, P = .03), not in those with PS (r = 0.22, P = .50). Conclusions: At similar levels of pressure overload, the right ventricle is less dilated and performs better in patients with PS compared with those with PAH.

J Am Soc Echocardiogr: 29 Aug 2011; epub ahead of print
Jurcut R, Giusca S, Ticulescu R, Popa E, ... Voigt JU, Ginghina C
J Am Soc Echocardiogr: 29 Aug 2011; epub ahead of print | PMID: 21873027
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Abstract

Differential Diagnosis and Clinical Implications of Remnants of the Right Valve of the Sinus Venosus.

Moral S, Ballesteros E, Huguet M, Panaro A, Palet J, Evangelista A
Anatomic variants of the remnants of the right valve of the sinus venosus in adults are common and usually observed on cardiac imaging studies. Because the anatomy and function of these vestiges are not well known, errors may occur in the differential diagnosis and treatment of patients with unclear images in the right atrium. Clinical implications may arise from (1) differential diagnosis with some diseases, especially when the remnants act as sites of attachment for masses; (2) the need for invasive treatment if the anatomic variant displays obstructive behavior; (3) the association between remnants and patent foramen ovale; and (4) secondary complications related to these structures in invasive procedures. Thus, the aim of this review is to provide cardiologists and radiologists specializing in cardiac imaging techniques with the basic anatomic information and clinical implications required to understand morphologic variants of right sinus venous valve vestiges in adults.

J Am Soc Echocardiogr: 19 Jan 2016; epub ahead of print
Moral S, Ballesteros E, Huguet M, Panaro A, Palet J, Evangelista A
J Am Soc Echocardiogr: 19 Jan 2016; epub ahead of print | PMID: 26787493
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Comprehensive Assessment of Changes in Left Atrial Volumes and Function After ST-Segment Elevation Acute Myocardial Infarction: Role of Two-Dimensional Speckle Tracking Strain Imaging.

Antoni ML, Ten Brinke EA, Marsan NA, Atary JZ, ... Bax JJ, Delgado V
Background: Left atrial (LA) size has been associated with adverse outcome in patients after acute myocardial infarction. However, data about the occurrence of late LA enlargement and changes in LA function during follow-up are scarce. The purpose of the current study was to evaluate changes in LA size and function during 1-year follow-up. Methods: The study population comprised 407 patients with acute myocardial infarction who were treated with primary percutaneous coronary intervention. At baseline and 12 months, two-dimensional echocardiography was performed to assess LA volumes and function using speckle-tracking strain and strain rate. Results: The mean age was 60 ± 11 years, and most patients were men (78%). LA maximal volume increased from 25 ± 8 to 28 ± 8 mL/m(2) (P < .001) from baseline to 1 year. Echocardiographic assessment at 1-year follow-up showed that 92 patients (25%) had developed LA remodeling (defined as an increase of ≥8 mL/m(2) in LA maximal volume). On multivariate analysis, only LA maximal volume at baseline (odds ratio, 0.95; 95% confidence interval, 0.91-0.98; P = .003) and LA strain at baseline (odds ratio, 0.94; 95% confidence interval, 0.92-0.97; P < .001) were independent predictors of LA remodeling during follow-up. Interestingly in patients without LA remodeling, no changes were observed in LA function during follow-up. However, in patients with LA remodeling, LA function significantly worsened during follow-up. In line, LA strain and strain rate were significantly lower at 12 months compared with baseline (24 ± 7% vs 27 ± 6%, P < .001, and 1.8 ± 0.5 vs 2.4 ± 0.7 sec(-1), P < .001, respectively). Conclusions: LA remodeling occurred in 22% of patients after acute myocardial infarction. In patients without LA remodeling, no changes in LA function were observed, but in patients with LA remodeling, LA function deteriorated significantly.

J Am Soc Echocardiogr: 08 Aug 2011; epub ahead of print
Antoni ML, Ten Brinke EA, Marsan NA, Atary JZ, ... Bax JJ, Delgado V
J Am Soc Echocardiogr: 08 Aug 2011; epub ahead of print | PMID: 21820865
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Abstract

The Role of Multimodality Imaging in Percutaneous Left Atrial Appendage Suture Ligation with the LARIAT Device.

Laura DM, Chinitz LA, Aizer A, Holmes DS, ... Kim EE, Saric M
Atrial fibrillation (AF), the most common cardiac arrhythmia, is a significant cause of embolic stroke. Although systemic anticoagulation is the primary strategy for preventing the thromboembolic complications of AF, anticoagulants carry major bleeding risks, and many patients have contraindications to their use. Because thromboembolism typically arises from a clot in the left atrial appendage (LAA), local therapeutic alternatives to systemic anticoagulation involving surgical or percutaneous exclusion of the LAA have been developed. Surgical exclusion of the LAA is typically performed only as an adjunct to other cardiac surgeries, thus limiting the number of eligible patients. Furthermore, surgical exclusion of the LAA is frequently incomplete, and thromboembolism may still occur. Percutaneous LAA exclusion includes two approaches: transseptal delivery of an occlusion device to the LAA and epicardial suture ligation of the LAA, the LARIAT procedure. In the LARIAT procedure, a pretied snare is placed around the epicardial surface of the LAA orifice via pericardial access. Proper snare placement is achieved with epicardial and endocardial magnet-tipped guidewires. The endocardial wire is advanced transvenously to the LAA apex after transseptal puncture. The epicardial wire, introduced into the pericardial space, achieves end-to-end union with the endocardial wire at the LAA apex. The snare is then placed over the LAA, tightened, and sutured. On the basis of early clinical experience, the LARIAT procedure has a high success rate of LAA exclusion with low risk for complications. The authors describe the indispensable role of real-time transesophageal echocardiography in the guidance of LAA epicardial suture ligation with the LARIAT device.

J Am Soc Echocardiogr: 29 May 2014; epub ahead of print
Laura DM, Chinitz LA, Aizer A, Holmes DS, ... Kim EE, Saric M
J Am Soc Echocardiogr: 29 May 2014; epub ahead of print | PMID: 24874974
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Abstract

Mean Strain Throughout the Heart Cycle by Longitudinal Two-Dimensional Speckle-Tracking Echocardiography Enables Early Prediction of Infarct Size.

Grenne B, Eek C, Sjøli B, Dahlslett T, ... Edvardsen T, Brunvand H
Background: Early prediction of infarct size directs therapy in patients with acute myocardial infarction (AMI). Global strain by echocardiography describes myocardial deformation and correlates with infarct size. However, peak strain measures deformation at a single time point, whereas ischemia and necrosis influence deformation throughout the heart cycle. It was hypothesized that the measurement of myocardial deformation throughout the heart cycle by mean strain is a more comprehensive expression of myocardial deformation. The aim of this study was to assess the ability of mean strain to predict infarct size and to identify large infarctions at admission and after revascularization in patients with AMI. Methods: Seventy-six patients with AMI were included. Echocardiographic measurements were performed at admission and after revascularization. Myocardial strain was calculated using speckle-tracking echocardiography. Infarct size was measured using contrast-enhanced magnetic resonance imaging ≥3 months after revascularization. Results: There were significant correlations between infarct size and longitudinal global mean strain, longitudinal global strain, and left ventricular ejection fraction (P < .0001), both at admission and after revascularization. The correlations improved after revascularization. Longitudinal global mean strain had the best correlation with infarct size and the best ability to discriminate between different infarct size categories. At admission, a cutoff value of -7.6 had 89% sensitivity, 88% specificity, and an area under the receiver operating characteristic curve of 0.92 for the identification of large infarctions. Prediction of infarct size improved for all parameters after revascularization. Conclusions: Longitudinal global mean strain provides improved early prediction of infarct size in patients with AMI compared with longitudinal global strain and left ventricular ejection fraction.

J Am Soc Echocardiogr: 18 Jul 2011; epub ahead of print
Grenne B, Eek C, Sjøli B, Dahlslett T, ... Edvardsen T, Brunvand H
J Am Soc Echocardiogr: 18 Jul 2011; epub ahead of print | PMID: 21764553
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Novel Pathogenetic Mechanisms and Structural Adaptations in Ischemic Mitral Regurgitation.

Silbiger JJ
Ischemic mitral regurgitation (MR) is a common complication of myocardial infarction thought to result from leaflet tethering caused by displacement of the papillary muscles that occurs as the left ventricle remodels. The author explores the possibility that left atrial remodeling may also play a role in the pathogenesis of ischemic MR, through a novel mechanism: atriogenic leaflet tethering. When ischemic MR is hemodynamically significant, the left ventricle compensates by dilating to preserve forward output using the Starling mechanism. Left ventricular dilatation, however, worsens MR by increasing the mitral valve regurgitant orifice, leading to a vicious cycle in which MR begets more MR. The author proposes that several structural adaptations play a role in reducing ischemic MR. In contrast to the compensatory effects of left ventricular enlargement, these may reduce, rather than increase, its severity. The suggested adaptations involve the mitral valve leaflets, the papillary muscles, the mitral annulus, and the left ventricular false tendons. This review describes the potential role each may play in reducing ischemic MR. Therapies that exploit these adaptations are also discussed.

J Am Soc Echocardiogr: 18 Aug 2013; epub ahead of print
Silbiger JJ
J Am Soc Echocardiogr: 18 Aug 2013; epub ahead of print | PMID: 23953703
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Can We Talk? Reflections on Effective Communication between Imager and Interventionalist in Congenital Heart Disease.

Kutty S, Delaney JW, Latson LA, Danford DA
The rapid proliferation of catheter-mediated treatments for congenital heart defects has brought with it a critical need for cooperation and communication among the numerous physicians supporting these new and complex procedures. New interdependencies between physicians in specialties including cardiac imaging, interventional cardiology, pediatric cardiology, anesthesia, cardiothoracic surgery, and radiology have become apparent, as centers have strived to develop the best systems to foster success. Best practices for congenital heart disease interventions mandate confident and timely input from an individual with excellent adjunctive imaging skills and a thorough understanding of the devices and procedures being used. The imager and interventionalist must share an understanding of what each offers for the procedure, use a common terminology and spatial orientation system, and convey concise and accurate information about what is needed, what is seen, and what cannot be seen. The goal of this article is to review how the cardiovascular imaging specialists and interventionalists can work together effectively to plan and execute catheter interventions for congenital heart disease.

J Am Soc Echocardiogr: 16 Jun 2013; epub ahead of print
Kutty S, Delaney JW, Latson LA, Danford DA
J Am Soc Echocardiogr: 16 Jun 2013; epub ahead of print | PMID: 23768692
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Intrapulmonary Shunt Is a Potentially Unrecognized Cause of Ischemic Stroke and Transient Ischemic Attack.

Abushora MY, Bhatia N, Alnabki Z, Shenoy M, Alshaher M, Stoddard MF
Background: Ischemic stroke is a major cause of mortality and disability. Transient ischemic attack (TIA) is a harbinger of stroke. The etiology of stroke in as many as 40% of patients remains undetermined after extensive evaluation. It was hypothesized that intrapulmonary shunt is a potential facilitator of cerebrovascular accident (CVA) or TIA. Methods: Patients undergoing clinically indicated transesophageal echocardiography were prospectively enrolled. Comprehensive multiplane transesophageal echocardiographic imaging was performed and saline contrast done to assess for intrapulmonary shunt and patent foramen ovale. Results: Three hundred twenty-one patients with either nonhemorrhagic CVA (n = 262) or TIA (n = 59) made up the stroke group. Three hundred twenty-one age-matched and gender-matched patients made up the control group. Intrapulmonary shunt occurred more frequently in the stroke group (72 of 321) compared with the control group (32 of 321) (22% vs 10%, P < .0001). Intrapulmonary shunt was an independent predictor of CVA and/or TIA (odds ratio, 2.6; P < .0001). In subjects with cryptogenic CVA or TIA (n = 71), intrapulmonary shunt occurred more frequently (25 of 71) than in the control group (5 of 71) (35% vs 7%, P < .0001). Intrapulmonary shunt was an independent multivariate predictor of CVA or TIA in patients with cryptogenic CVA or TIA (odds ratio, 6.3; P < .005). Conclusions: These results suggest that intrapulmonary shunt is a potentially unrecognized facilitator of CVA and TIA, especially in patients with cryptogenic CVA and TIA. Future studies assessing the prognostic significance of intrapulmonary shunt on cerebral vascular event recurrence rates in patients after initial CVA or TIA would be of great interest.

J Am Soc Echocardiogr: 13 May 2013; epub ahead of print
Abushora MY, Bhatia N, Alnabki Z, Shenoy M, Alshaher M, Stoddard MF
J Am Soc Echocardiogr: 13 May 2013; epub ahead of print | PMID: 23669596
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Achieving High-Value Cardiac Imaging: Challenges and Opportunities.

Wiener DH
Cardiac imaging is under intense scrutiny as a contributor to health care costs, with multiple initiatives under way to reduce and eliminate inappropriate testing. Appropriate use criteria are valuable guides to selecting imaging studies but until recently have focused on the test rather than the patient. Patient-centered means are needed to define the true value of imaging for patients in specific clinical situations. This article provides a definition of high-value cardiac imaging. A paradigm to judge the efficacy of echocardiography in the absence of randomized controlled trials is presented. Candidate clinical scenarios are proposed in which echocardiography constitutes high-value imaging, as well as stratagems to increase the likelihood that high-value cardiac imaging takes place in those circumstances.

J Am Soc Echocardiogr: 06 Oct 2013; epub ahead of print
Wiener DH
J Am Soc Echocardiogr: 06 Oct 2013; epub ahead of print | PMID: 24094554
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Echocardiography: Profiling of the Athlete\'s Heart.

Paterick TE, Gordon T, Spiegel D
Cardiovascular physiologic remodeling associated with athleticism may mimic many of the features of genetic and acquired heart disease. The most pervasive dilemma is distinguishing between normal and abnormal physiologic remodeling in an athlete\'s heart. Imaging examinations, such as magnetic resonance imaging and computed tomography, which focus predominantly on anatomy, and electrocardiography, which monitors electrical components, do not simultaneously evaluate cardiac anatomy and physiology. Despite nonlinear anatomic and electrical remodeling, the athlete\'s heart retains normal or supernormal myocyte function, whereas a diseased heart has various degrees of pathophysiology. Echocardiography is the only cost-effective, validated imaging modality that is widely available and capable of simultaneously quantifying variable anatomic and physiologic features. Doppler echocardiography substantially redefines the understanding of normal remodeling from preemergent and overt disease.

J Am Soc Echocardiogr: 20 Jul 2014; epub ahead of print
Paterick TE, Gordon T, Spiegel D
J Am Soc Echocardiogr: 20 Jul 2014; epub ahead of print | PMID: 25042411
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The Incremental Prognostic Value of Echocardiography in Asymptomatic Stage A Heart Failure.

Carerj S, La Carrubba S, Antonini-Canterin F, Di Salvo G, ... Di Bello V, on behalf of the Research Group of the Italian Society of Cardiovascular Echography
Objective: This multicenter study consisted of echocardiographic examination of subjects with stage A heart failure (HF) with cardiovascular risk factors and normal electrocardiogram and clinical examination results to (a) define whether stage A subjects with risk factors are really free of functional or structural cardiac abnormalities and (b) assess the impact of the presence of risk factors and incremental value of echocardiographic parameters in the prediction of progression of HF or in the development of cardiovascular events. Methods: A total of 1097 asymptomatic subjects underwent echocardiographic examination as a screening evaluation in the presence of cardiovascular risk factors. Left ventricular (LV) dysfunction, both systolic (ejection fraction) and diastolic (transmitral flow velocity pattern), was evaluated according to standard criteria. The subjects were divided according to different criteria: the presence of one or more risk factors, presence or absence of LV systolic dysfunction, and presence or absence of LV diastolic dysfunction. A follow-up period of 26 +/- 11 months was performed, observing primary (cardiac death, myocardial infarction, coronary artery bypass grafting, percutaneous transluminal coronary angioplasty, acute pulmonary edema, stroke, and transient ischemic attack) and secondary (cardiologist-made diagnosis of HF and HF hospitalization) end points. Results: The multivariate analysis for independent predictors of primary end points showed that age (P = .001), gender (P = .02), dyslipidemia (P = .01), obesity (P = .001), and systolic dysfunction (P = .048) represented the significant predictors. The multivariate logistic regression analysis for independent predictors of secondary end points showed that gender (P = .02), LV systolic dysfunction (P = .01), and LV diastolic dysfunction (P < .01) represented the significant predictors. The multivariate analysis for independent predictors of combined end points showed that only age (P < .003), gender (male: P < .001), obesity (P < .04), and systolic dysfunction (P < .001) represented the significant predictors. Echocardiography showed a high incremental value in the detection of systolic LV dysfunction and the prediction of cardiovascular events during follow-up in subjects with at least two risk factors. Conclusion: This study demonstrated that preclinical functional or structural myocardial abnormalities could be detected by echocardiography in asymptomatic subjects with two or more cardiovascular risk factors and without electrocardiogram abnormalities (stage A of HF classification). The presence or absence of LV systolic dysfunction or LV diastolic dysfunction, as demonstrated by echocardiography, has an incremental value to cardiovascular risk factors in predicting both the evolution toward more severe HF stage C and the occurrence of cardiovascular events.

J Am Soc Echocardiogr: 27 Jul 2010; epub ahead of print
Carerj S, La Carrubba S, Antonini-Canterin F, Di Salvo G, ... Di Bello V, on behalf of the Research Group of the Italian Society of Cardiovascular Echography
J Am Soc Echocardiogr: 27 Jul 2010; epub ahead of print | PMID: 20659788
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Pulmonary Artery Acceleration Time Provides an Accurate Estimate of Systolic Pulmonary Arterial Pressure during Transthoracic Echocardiography.

Yared K, Noseworthy P, Weyman AE, McCabe E, Picard MH, Baggish AL
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 number of patients. To date, in the absence of TR, no noninvasive method of deriving EPSPAP has been developed. 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 measure the peak velocity of TR (TR(Vmax)), and EPSPAP was calculated as 4 × TR(Vmax)(2) + 10 mm Hg (to account for right atrial pressure). The relationship between PAAT and EPSPAP was then assessed. Results: Adequate imaging to measure PAAT was available in 99.6% of patients (498 of 500), but 25.3% (126 of 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 TR(Vmax) (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 log(10)(EPSPAP) = 0.004(PAAT) + 2.1 (P < .001). Conclusions: PAAT is routinely obtainable and correlates strongly with both TR(Vmax) 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: 22 Apr 2011; epub ahead of print
Yared K, Noseworthy P, Weyman AE, McCabe E, Picard MH, Baggish AL
J Am Soc Echocardiogr: 22 Apr 2011; epub ahead of print | PMID: 21511434
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EAE/ASE Recommendations for the Use of Echocardiography in New Transcatheter Interventions for Valvular Heart Disease.

Zamorano JL, Badano LP, Bruce C, Chan KL, ... Vanoverschelde JL, Gillam LD
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 trans-catheter 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.

J Am Soc Echocardiogr: 26 Aug 2011; 24:937-965
Zamorano JL, Badano LP, Bruce C, Chan KL, ... Vanoverschelde JL, Gillam LD
J Am Soc Echocardiogr: 26 Aug 2011; 24:937-965 | PMID: 21867869
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Right Ventricular Involvement in Coronary Artery Disease: Role of Echocardiography for Diagnosis and Prognosis.

Rallidis LS, Makavos G, Nihoyannopoulos P
The right ventricle differs from the left ventricle in many anatomic and physiologic aspects. This disparity renders the right ventricle less vulnerable to ischemia and less susceptible to myocardial injury when right coronary artery occlusion occurs compared with the extent of left ventricular dysfunction during left coronary artery occlusion. Acute right ventricular (RV) myocardial infarction is usually caused by proximal right coronary artery occlusion and therefore is usually associated with inferior myocardial infarction. Conventional echocardiography along with Doppler tissue imaging has played a significant role in early diagnosis of RV myocardial infarction and has a role in prognostic stratification. Stress echocardiography is less validated and more technically demanding in detecting RV reversible dysfunction compared with left ventricular dysfunction. The threshold of RV ischemia during stress echocardiography is higher compared with left ventricular ischemia and usually affects the inferior RV wall. Further studies, particularly with the use of novel echocardiographic techniques such as speckle-tracking and three-dimensional echocardiography, may be required to better elucidate the role of the right ventricle in coronary artery disease.

J Am Soc Echocardiogr: 12 Jan 2014; epub ahead of print
Rallidis LS, Makavos G, Nihoyannopoulos P
J Am Soc Echocardiogr: 12 Jan 2014; epub ahead of print | PMID: 24412341
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Left Ventricular Adaptation to Acute Hypoxia: A Speckle-Tracking Echocardiography Study.

Dedobbeleer C, Hadefi A, Naeije R, Unger P
Background: Hypoxia depresses myocardial contractility in vitro but does not affect or may even improve indices of myocardial performance in vivo, possibly through associated changes in autonomic nervous system tone. The aim of this study was to explore the effects of hypoxic breathing on speckle-tracking echocardiographic indices of left ventricular function, with and without β1-adrenergic inhibition. Methods: Speckle-tracking echocardiography was performed in 21 healthy volunteers in normoxia and after 30 min of hypoxic breathing (fraction of inspired oxygen, 0.12). Measurements were also obtained after the administration of atropine in normoxia (n = 21) and after bisoprolol intake in normoxia (n = 6) and in hypoxia (n = 10). Results: Hypoxia increased heart rate (from 68 ± 11 to 74 ± 9 beats/min, P = .001), without changing mean blood pressure (P = NS), and decreased total peripheral resistance (P = .003). Myocardial deformation magnitude increased (circumferential strain, -19.6 ± 1.9% vs -21.2 ± 2.5%; radial strain, 19.2 ± 3.7% vs 22.6 ± 4.1%, P < .05; longitudinal and circumferential strain rate, -0.88 ± 0.11 vs -0.99 ± 0.15 sec(-1) and -1.03 ± 0.16 vs -1.18 ± 0.18 sec(-1), respectively, P < .05 for both; peak twist, 8.98 ± 3.2° vs 11.1 ± 2.9°, P < .05). Except for peak twist, these deformation parameters were correlated with total peripheral resistance (P < .05). Atropine increased only longitudinal strain rate magnitude (-0.88 ± 0.11 vs -0.97 ± 0.14 sec(-1), P < .05). The increased magnitude of myocardial deformation persisted in hypoxia under bisoprolol (P < .05). In normoxia, bisoprolol decreased heart rate (73 ± 10 vs 54 ± 7 beats/min, P = .0005), mean blood pressure (88 ± 7 vs 81 ± 4 mm Hg, P = .0027), without altering deformation. Conclusions: Hypoxic breathing increases left ventricular deformation magnitude in normal subjects, and this effect may not be attributed to hypoxia-induced tachycardia or β1-adrenergic pathway changes but to hypoxia-induced systemic vasodilation.

J Am Soc Echocardiogr: 26 May 2013; epub ahead of print
Dedobbeleer C, Hadefi A, Naeije R, Unger P
J Am Soc Echocardiogr: 26 May 2013; epub ahead of print | PMID: 23706341
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Right Ventricular Function Is a Determinant of Long-Term Survival after Cardiac Resynchronization Therapy.

Sade LE, Ozin B, Atar I, Demir O, Demirtaş S, Müderrisoğlu H
Background: Right ventricular (RV) dysfunction is a marker of poor prognosis in patients with heart failure. The aim of this study was to investigate the impact of RV function on the long-term outcomes of patients undergoing cardiac resynchronization therapy (CRT). Methods: A total of 120 consecutive patients treated with CRT according to guideline criteria were followed over 5 years. Comprehensive echocardiographic analyses of RV function and radial and longitudinal mechanical left ventricular dyssynchrony were performed at baseline and 6 months after implantation. RV function was evaluated by two-dimensional longitudinal strain of the free wall, fractional area change, tricuspid annular plane systolic excursion, and tricuspid annular systolic velocity. Long-term follow-up events were defined as all-cause mortality, heart transplantation, or assist device implantation. Results: Long-term events occurred in 38 patients. Among the studied variables for RV function, RV strain < 18% had the highest sensitivity (79%) and specificity (84%) to predict a poor outcome after CRT (area under curve, 0.821; P < .0001). When adjusted for confounding baseline variables of ischemic etiology, mechanical dyssynchrony, left ventricular end-systolic volume, mitral regurgitation, and medical therapy, RV dysfunction remained independently associated with outcomes, indicating a 5.7-fold increased risk for hard events (P < .0001). Conclusions: Preserved RV function as assessed by speckle-tracking strain imaging appears to be an independent predictor of long-term event-free survival after CRT.

J Am Soc Echocardiogr: 23 Apr 2013; epub ahead of print
Sade LE, Ozin B, Atar I, Demir O, Demirtaş S, Müderrisoğlu H
J Am Soc Echocardiogr: 23 Apr 2013; epub ahead of print | PMID: 23611060
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Echocardiographic Methods, Quality Review, and Measurement Accuracy in a Randomized Multicenter Clinical Trial of Marfan Syndrome.

Selamet Tierney ES, Levine JC, Chen S, Bradley TJ, ... Lacro RV, Pediatric Heart Network Investigators
Background: The Pediatric Heart Network is conducting a large international randomized trial to compare aortic root growth and other cardiovascular outcomes in 608 subjects with Marfan syndrome randomized to receive atenolol or losartan for 3 years. The authors report here the echocardiographic methods and baseline echocardiographic characteristics of the randomized subjects, describe the interobserver agreement of aortic measurements, and identify factors influencing agreement. Methods: Individuals aged 6 months to 25 years who met the original Ghent criteria and had body surface area-adjusted maximum aortic root diameter (ROOTmax) Z scores > 3 were eligible for inclusion. The primary outcome measure for the trial is the change over time in ROOTmaxZ score. A detailed echocardiographic protocol was established and implemented across 22 centers, with an extensive training and quality review process. Results: Interobserver agreement for the aortic measurements was excellent, with intraclass correlation coefficients ranging from 0.921 to 0.989. Lower interobserver percentage error in ROOTmax measurements was independently associated (model R(2) = 0.15) with better image quality (P = .002) and later study reading date (P < .001). Echocardiographic characteristics of the randomized subjects did not differ by treatment arm. Subjects with ROOTmaxZ scores ≥ 4.5 (36%) were more likely to have mitral valve prolapse and dilation of the main pulmonary artery and left ventricle, but there were no differences in aortic regurgitation, aortic stiffness indices, mitral regurgitation, or left ventricular function compared with subjects with ROOTmaxZ scores < 4.5. Conclusions: The echocardiographic methodology, training, and quality review process resulted in a robust evaluation of aortic root dimensions, with excellent reproducibility.

J Am Soc Echocardiogr: 14 Apr 2013; epub ahead of print
Selamet Tierney ES, Levine JC, Chen S, Bradley TJ, ... Lacro RV, Pediatric Heart Network Investigators
J Am Soc Echocardiogr: 14 Apr 2013; epub ahead of print | PMID: 23582510
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Abstract

Relationship between Longitudinal Strain and Symptomatic Status in Aortic Stenosis.

Attias D, Macron L, Dreyfus J, Monin JL, ... Vahanian A, Messika-Zeitoun D
Background: Global longitudinal strain (GLS) and basal longitudinal strain (BLS) assessed using two-dimensional speckle-tracking imaging have been proposed as subtle markers of left ventricular (LV) systolic dysfunction with potential prognostic value in patients with aortic stenosis (AS). The aim of this study was to evaluate the relationship between longitudinal strain and symptomatic status in patients with AS. Methods: GLS and BLS were measured in 171 patients with pure, isolated, at least mild AS prospectively enrolled at two institutions. The population was divided into four groups: asymptomatic nonsevere AS (n = 55), asymptomatic severe AS with preserved LV ejection fraction (LVEF; ≥50%) (n = 37), symptomatic severe AS with preserved LVEF (n = 60), and severe AS with reduced LVEF (<50%) (n = 19). Results: GLS was significantly different among the four groups (P < .0001), but the difference was due mainly to patients with reduced LVEFs. In addition, there was an important overlap among the groups, and in multivariate analysis, after adjustment for age, gender, AS severity, and LVEF, GLS was not an independent predictor of symptomatic status (P = .07). BLS was also significantly different among the four groups (P < .0001) but in contrast was independently associated with symptomatic status (P < .0001). However, as for GLS, there was an important overlap between groups and differences were close to intraobserver or interobserver variability (1.3 ± 1.1% and 2.0 ± 1.6%, respectively). Conclusions: In this prospective multicenter cohort of patients with wide ranges of AS severity, symptoms, and LVEFs, BLS but not GLS was independently associated with symptomatic status. However, there was an important overlap among groups, and differences were close to measurements\' reproducibility, raising caution regarding the use of longitudinal strain, at least as a single criterion, in the decision-making process for patients with severe asymptomatic AS.

J Am Soc Echocardiogr: 16 Jun 2013; epub ahead of print
Attias D, Macron L, Dreyfus J, Monin JL, ... Vahanian A, Messika-Zeitoun D
J Am Soc Echocardiogr: 16 Jun 2013; epub ahead of print | PMID: 23768690
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Prognostic Value of Right Ventricular Two-Dimensional Global Strain in Patients Referred for Cardiac Surgery.

Ternacle J, Berry M, Cognet T, Kloeckner M, ... Gueret P, Lim P
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 < 35%, 34 (13.6%) had TAPSE < 16 mm, and 99 (39.6%) had impaired RV-GLS > -21% (35% with normal RVFAC ≥ 35%). Postoperative death (n = 25) was higher in patients with abnormal RV-GLS > -21% (22% vs 3%; P < .0001), TAPSE < 16 mm (24% vs 8%; P = .007), and RVFAC < 35% (32% vs 9%; 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 < 35% (20% vs 32%; 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.

J Am Soc Echocardiogr: 28 Apr 2013; epub ahead of print
Ternacle J, Berry M, Cognet T, Kloeckner M, ... Gueret P, Lim P
J Am Soc Echocardiogr: 28 Apr 2013; epub ahead of print | PMID: 23623594
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Effect of Pharmacologic Increases in Afterload on Left Ventricular Rotation and Strain in a Rabbit Model.

Ho JK, Zhou W, Ashraf M, Swaminathan M, Sahn D, Mahajan A
Background: Assessment of left ventricular rotational mechanics and myocardial deformation may provide new insight into both systolic and diastolic function. However, the effects of increasing afterload on these measures of cardiac function are poorly understood. The aim of this study was to identify the changes in left ventricular function and rotational mechanics during increasing pharmacologic afterload. Methods: In 14 anesthetized rabbits, two-dimensional speckle-tracking echocardiographic images and left ventricular pressure-volume loops were acquired at baseline and during norepinephrine, phenylephrine, and vasopressin infusion at increasing doses. Maximal ventricular elastance, arterial elastance, ventricular-arterial coupling, dP/dt, the time constant of relaxation, and other hemodynamic parameters were determined. Results: An increase in dP/dtmax with norepinephrine and phenylephrine and a decrease with vasopressin at escalating doses were detected. Ventricular-arterial coupling was preserved with norepinephrine and phenylephrine but decreased with vasopressin (P < .05). Apical rotation, rotational rate, and strain were preserved during the norepinephrine and phenylephrine infusions but were reduced with vasopressin (P < .05). Apical rotation and circumferential strain were significantly correlated with both ventricular-arterial coupling (r = 0.84 and r = 0.81) and dP/dtmax (r = -0.81 and r = -0.77). High-dose vasopressin decreased the diastolic time constant of relaxation and dP/dtmin while reducing apical untwisting rate. Conclusions: Pharmacologic increases in afterload with vasopressin resulted in greater derangements in ventricular-arterial coupling and cardiac performance compared with norepinephrine and phenylephrine. Rotation and strain correlated well with invasively determined measures and can be used to assess afterload-induced alteration in cardiac function.

J Am Soc Echocardiogr: 23 Apr 2013; epub ahead of print
Ho JK, Zhou W, Ashraf M, Swaminathan M, Sahn D, Mahajan A
J Am Soc Echocardiogr: 23 Apr 2013; epub ahead of print | PMID: 23611057
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Left Atrial Mechanics: Echocardiographic Assessment and Clinical Implications.

Vieira MJ, Teixeira R, Gonçalves L, Gersh BJ
The importance of the left atrium in cardiovascular performance has long been acknowledged. Quantitative assessment of left atrial (LA) function is laborious, requiring invasive pressure-volume loops and thus precluding its routine clinical use. In recent years, novel postprocessing imaging methodologies have emerged, providing a complementary approach for the assessment of the left atrium. Atrial strain and strain rate obtained using either Doppler tissue imaging or two-dimensional speckle-tracking echocardiography have proved to be feasible and reproducible techniques to evaluate LA mechanics. It is essential to fully understand the clinical applications, advantages, and limitations of LA strain and strain rate analysis. Furthermore, the technique\'s prognostic value and utility in therapeutic decisions also need further elucidation. The aim of this review is to provide a critical appraisal of LA mechanics. The authors describe the fundamental concepts and methodology of LA strain and strain rate analysis, the reference values reported with different imaging techniques, and the clinical implications.

J Am Soc Echocardiogr: 23 Mar 2014; epub ahead of print
Vieira MJ, Teixeira R, Gonçalves L, Gersh BJ
J Am Soc Echocardiogr: 23 Mar 2014; epub ahead of print | PMID: 24656882
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Prognostic Value of Left Atrial Volume in Asymptomatic Organic Mitral Regurgitation.

Arias A, Pizarro R, Oberti P, Falconi M, ... Funes D, Cagide A
Background: Basal left atrial volume (LAV) indexed to body surface area (LAVI) predicts adverse events in patients with organic mitral regurgitation, but information is lacking regarding change in left atrial volume during follow-up. Methods: One hundred forty-four asymptomatic patients (mean age, 71 ± 12 years; 66% women; mean ejection fraction, 66 ± 4.8%) with moderate to severe mitral regurgitation were prospectively included, with a median follow-up period of 2.76 years (interquartile range, 1.86-3.48 years). Results: Fifty-four patients (37.50%) reached the combined end point of dyspnea and/or systolic dysfunction. Both basal and change in LAV were independently associated with the combined end point on multivariate analysis: for basal LAVI ≥ 55 mL/m(2), odds ratio, 2.26 (95% confidence interval, 1.04-4.88; P = .038), and for change in LAV ≥ 14 mL, odds ratio, 7.32 (95% confidence interval, 3.25-16.48; P < .001), adjusted for effective regurgitant orifice area and deceleration time. Combined event-free survival at 1, 2, and 3 years was significantly less in patients with basal LAVI ≥ 55 mL/m(2) (75%, 58%, and 43%) than in those with basal LAVI < 55 mL/m(2) (95%, 89%, and 77%) (log-rank test = 15.38, P = .0001). The incidence of the combined end point was highest (88%) in patients with basal LAVI ≥ 55 mL/m(2) and change in LAV ≥ 14 mL. Conclusions: Measurement of basal LAV and its increase during follow-up predict an adverse course in patients with moderate and severe asymptomatic mitral regurgitation. Hence, its assessment could be incorporated into the currently used algorithm for risk stratification and decision making in this group of patients.

J Am Soc Echocardiogr: 28 Apr 2013; epub ahead of print
Arias A, Pizarro R, Oberti P, Falconi M, ... Funes D, Cagide A
J Am Soc Echocardiogr: 28 Apr 2013; epub ahead of print | PMID: 23623592
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Comprehensive Analysis of Left Ventricular Geometry and Function by Three-Dimensional Echocardiography in Healthy Adults.

Muraru D, Badano LP, Peluso D, Bianco LD, ... Zoppellaro G, Iliceto S
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.

J Am Soc Echocardiogr: 23 Apr 2013; epub ahead of print
Muraru D, Badano LP, Peluso D, Bianco LD, ... Zoppellaro G, Iliceto S
J Am Soc Echocardiogr: 23 Apr 2013; epub ahead of print | PMID: 23611056
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Validation of Noninvasive Measurements of Cardiac Output in Mice Using Echocardiography.

Tournoux F, Petersen B, Thibault H, Zou L, ... Picard MH, Scherrer-Crosbie M
Background: Although multiple echocardiographic methods exist to calculate cardiac output (CO), they have not been validated in mice using a reference method. Methods: Echocardiographic and flow probe measurements of CO were obtained in mice before and after albumin infusion and inferior vena cava occlusions. Echocardiography was also performed before and after endotoxin injection. Cardiac output was calculated using left ventricular volumes obtained from an M-mode or a two-dimensional view, left ventricular stroke volume calculated using the pulmonary flow, or estimated by the measurement of pulmonary velocity time integral (VTI). Results: Close correlations were demonstrated between flow probe-measured CO and all echocardiographic measurements of CO. All echocardiographic-derived CO overestimated the flow probe-measured CO. Two-dimensional image-derived CO was associated with the smallest overestimation of CO. Interobserver variability was lowest for pulmonary VTI-derived CO. Conclusion: In mice, CO calculated from two-dimensional parasternal long-axis images is most accurate when compared with flow probe measurements; however, pulmonary VTI-derived CO is subject to less variability.

J Am Soc Echocardiogr: 14 Feb 2011; epub ahead of print
Tournoux F, Petersen B, Thibault H, Zou L, ... Picard MH, Scherrer-Crosbie M
J Am Soc Echocardiogr: 14 Feb 2011; epub ahead of print | PMID: 21315557
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Application of Speckle-Tracking in the Evaluation of Carotid Artery Function in Subjects with Hypertension and Diabetes.

Yang EY, Brunner G, Dokainish H, Hartley CJ, ... Nagueh SF, Nambi V
Background: Speckle-tracking enables direct tracking of carotid arterial wall motion. Timing intervals determined with carotid speckle-tracking and slopes calculated from carotid artery area versus cardiac cycle curves may provide further information on arterial function and stiffness. The proposed arterial stiffness parameters were examined in healthy controls (n = 20), nondiabetic patients with hypertension (n = 20), and patients with type 2 diabetes (n = 21). Methods: Bilateral electrocardiographically gated ultrasonograms of the distal common carotid artery were acquired using a 12-MHz vascular probe. Four timing intervals were derived from speckle-tracked carotid arterial strain curves: (1) carotid predistension period, (2) peak carotid arterial strain time, (3) arterial distension period, and (4) arterial diastolic time. In addition, carotid artery area curves were recorded over the cardiac cycle and subdivided into four segments, S1 to S4, relating to arterial distention and contraction periods. Results: Mean far wall predistension period and peak carotid arterial strain time were more delayed in patients with diabetes and hypertension than in controls. Global mean arterial distension period was prolonged and arterial diastolic time was shorter in patients with hypertension and diabetes than in controls. Slopes of segments S2 and S4 were markedly steeper in the combined group of patients with hypertension and diabetes compared with healthy controls (P = .03 and P = .02, respectively). Conclusions: Speckle-tracking-based measures of arterial stiffness may provide potential additive value in assessing vascular function in patients at risk for cardiovascular disease.

J Am Soc Echocardiogr: 12 Jun 2013; epub ahead of print
Yang EY, Brunner G, Dokainish H, Hartley CJ, ... Nagueh SF, Nambi V
J Am Soc Echocardiogr: 12 Jun 2013; epub ahead of print | PMID: 23759168
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Intraoperative Transesophageal Echocardiography for Surgical Repair of Mitral Regurgitation.

Sidebotham DA, Allen SJ, Gerber IL, Fayers T
Surgical repair of the mitral valve is being increasingly performed to treat severe mitral regurgitation. Transesophageal echocardiography is an essential tool for assessing valvular function and guiding surgical decision making during the perioperative period. A careful and systematic transesophageal echocardiographic examination is necessary to ensure that appropriate information is obtained and that the correct diagnoses are obtained before and after repair. The purpose of this article is to provide a practical guide for perioperative echocardiographers caring for patients undergoing surgical repair of mitral regurgitation. A guide to performing a systematic transesophageal echocardiographic examination of the mitral valve is provided, along with an approach to prerepair and postrepair assessment. Additionally, the anatomy and function of normal and regurgitant mitral valves are reviewed.

J Am Soc Echocardiogr: 17 Feb 2014; epub ahead of print
Sidebotham DA, Allen SJ, Gerber IL, Fayers T
J Am Soc Echocardiogr: 17 Feb 2014; epub ahead of print | PMID: 24534653
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Impact of Valvuloarterial Impedance on 2-Year Outcome of Patients Undergoing Transcatheter Aortic Valve Implantation.

Katsanos S, Yiu KH, Clavel MA, Rodés-Cabau J, ... Pibarot P, Delgado V
Background: Elderly patients with severe aortic stenosis undergoing transcatheter aortic valve implantation (TAVI) often have increased calcification and fibrosis of the aorta. Indices that account for the severity of valvular obstruction and systemic vascular impedance may better assess total left ventricular afterload. The aims of the present study were to evaluate changes in valvuloarterial impedance (Zva), systemic arterial compliance, and systemic vascular resistance after TAVI and to investigate the prognostic value of these parameters. Methods: A total of 116 patients (49% men; mean age, 81 ± 8 years) with symptomatic severe aortic stenosis underwent TAVI. Zva, systemic arterial compliance, and systemic vascular resistance were measured at baseline and 1 and 12 months after TAVI. The primary end point was all-cause mortality. Results: After TAVI, there was a significant reduction in Zva (from 5.40 ± 1.52 mm Hg/mL/m(2) at baseline to 4.13 ± 1.17 mm Hg/mL/m(2) at 1 month and 4.35 ± 1.38 mm Hg/mL/m(2) at 1 year, P < .001). Systemic arterial compliance (from 0.57 ± 0.27 to 0.57 ± 0.28 and 0.53 ± 0.27 mL/m(2)/mm Hg, P = .408) and systemic vascular resistance (from 1,938 ± 669 to 1,856 ± 888 and 1,871 ± 767, dyne·s·cm(-5), P = .697) did not change significantly over time. During a median follow-up period of 25 months, survival rates of patients with baseline Zva ≥ 5 mm Hg/mL/m(2) were lower compared with those with Zva < 5 mm Hg/mL/m(2) (82% vs 91%, respectively, log-rank P = .04). On multivariate Cox proportional-hazards analysis, baseline Zva was independently associated with all-cause mortality (hazard ratio, 1.48; 95% confidence interval, 1.05-2.07; P = .025). Conclusions: In patients undergoing TAVI, there is a significant postprocedural reduction in Zva, but there is no reduction in systemic arterial compliance or vascular resistance. Baseline Zva is an independent predictor of overall mortality at 2-year follow-up.

J Am Soc Echocardiogr: 13 May 2013; epub ahead of print
Katsanos S, Yiu KH, Clavel MA, Rodés-Cabau J, ... Pibarot P, Delgado V
J Am Soc Echocardiogr: 13 May 2013; epub ahead of print | PMID: 23669595
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Localized Transvalvular Pressure Gradients in Mitral Bileaflet Mechanical Heart Valves and Impact on Gradient Overestimation by Doppler.

Evin M, Pibarot P, Guivier-Curien C, Tanné D, Kadem L, Rieu R
Background: It has been reported that localized high velocity may be recorded by continuous-wave Doppler interrogation through the smaller central orifices of bileaflet mechanical heart valves (BMHV) and that this may result in overestimation of the transvalvular pressure gradient (TPG). However, the prevalence and clinical relevance of this phenomenon remain unclear, particularly for BMHVs in the mitral position. The objective of this in vitro study was to assess the presence and magnitude of localized high velocity in mitral BMHVs as well as its impact on TPG overestimation by Doppler. Methods: Nine BMHVs were tested under nine different flow conditions (volumes and flow waveforms) in a simulator specifically designed to assess mitral valve hemodynamics. Flow velocity was measured at three different locations (leading edge, midleaflets, and trailing edge) within the central and lateral orifices of the BMHVs using pulsed-wave Doppler. TPG was measured by pulsed-wave and continuous-wave Doppler and by catheterization. Results: The maximum flow velocity occurred within the central orifice of the BMHV in 61% of the 81 tested conditions. This locally higher velocity within the central orifice predominantly occurred at the leading edge of the prosthesis. Doppler overestimated mean TPG by an average of 5% to 10% compared with catheterization. The magnitude of the localized high velocity and ensuing overestimation of TPG by Doppler was more important at higher mitral flow volumes (P < .0001) as well as in BMHVs with smaller internal ring diameters (P < .0001). Conclusions: This study shows that the flow velocity distribution within the three orifices of mitral BMHVs is not uniform and that higher velocity occurs more frequently, but not always, within the inflow aspect of the central orifice. In most mitral BMHVs and flow conditions, this localized high-velocity phenomenon causes small overestimation of TPGs (<2 mm Hg and <10%) by Doppler and is thus not clinically relevant. However, in small mitral BMHVs exposed to high flow rates, the overestimation of TPG due to localized high velocity could become more important and overlap with the range of gradients found in patients with prosthesis dysfunction or prosthesis-patient mismatch.

J Am Soc Echocardiogr: 23 Apr 2013; epub ahead of print
Evin M, Pibarot P, Guivier-Curien C, Tanné D, Kadem L, Rieu R
J Am Soc Echocardiogr: 23 Apr 2013; epub ahead of print | PMID: 23611059
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Abstract

Interpretation of Remotely Downloaded Pocket-Size Cardiac Ultrasound Images on a Web-Enabled Smartphone: Validation Against Workstation Evaluation.

Choi BG, Mukherjee M, Dala P, Young HA, ... Katz RJ, Lewis JF
Background: Pocket-size ultrasound has increased echocardiographic portability, but expert point-of-care interpretation may not be readily available. The aim of this study was to test the hypothesis that remote interpretation on a smartphone with dedicated medical imaging software can be as accurate as on a workstation. Methods: Eighty-nine patients in a remote Honduran village underwent echocardiography by a nonexpert using a pocket-size ultrasound device. Images were sent for verification of point-of-care diagnosis to two expert echocardiographers in the United States reading on a workstation. Studies were then anonymized, randomly ordered, and reinterpreted on a smartphone with a dedicated, Health Insurance Portability and Accountability Act-compliant application. Point-of-care diagnosis was considered accurate if any abnormal finding was matched and categorized at the same level of severity (mild, moderate, or severe) by either expert interpretation. Results: The mean age was 54 ± 23 years, and 57% of patients were women. The most common indications for echocardiography were arrhythmia (33%), cardiomyopathy (28%), and syncope (15%). Using the workstation, point-of-care diagnoses were changed in 38% of cases by expert overread (41% left ventricular function correction, 38% valvulopathy correction, 18% poor image quality). Expert interobserver agreement was excellent at 82%, with a Cohen\'s κ value of 0.82 (95% confidence interval, 0.70-0.94). Intraobserver agreement comparing interpretations on workstations and smartphones was 90%, with a Cohen\'s κ value of 0.86 (95% confidence interval, 0.76-0.97), signifying excellent intertechnology agreement. Conclusions: Remote expert echocardiographic interpretation can provide backup support to point-of-care diagnosis by nonexperts when read on a dedicated smartphone-based application. Mobile-to-mobile consultation may improve access in previously inaccessible locations to accurate echocardiographic interpretation by experienced cardiologists.

J Am Soc Echocardiogr: 19 Sep 2011; epub ahead of print
Choi BG, Mukherjee M, Dala P, Young HA, ... Katz RJ, Lewis JF
J Am Soc Echocardiogr: 19 Sep 2011; epub ahead of print | PMID: 21925836
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Comparison of Factors Associated with Carotid Intima-Media Thickness in the Multi-Ethnic Study of Atherosclerosis (MESA) and the Heinz Nixdorf Recall Study (HNR).

Bauer M, Delaney JA, Möhlenkamp S, Jöckel KH, ... McClelland RL, Multi-Ethnic Study of Atherosclerosis and the Investigator Group of the Heinz Nixdorf Recall Study
Background: The measurement of carotid intima-media thickness (CIMT) is a valid method to quantify levels of atherosclerosis. The present study was conducted to compare the strengths of associations between CIMT and cardiovascular risk factors in two different populations. Methods: The Multi-Ethnic Study of Atherosclerosis (MESA) and the Heinz Nixdorf Recall Study (HNR) are two population-based prospective cohort studies of subclinical cardiovascular disease. All Caucasian subjects aged 45 to 75 years from these cohorts who were free of baseline cardiovascular disease (n = 2,820 in HNR, n = 2,270 in MESA) were combined. CIMT images were obtained using B-mode sonography at the right and left common carotid artery and measured 1 cm starting from the bulb. Results: In both studies, age, male sex, and systolic blood pressure showed the strongest association (P < .0001 for each) for a higher CIMT. The mean of mean far wall CIMT was slightly higher in MESA participants (0.71 vs 0.67 mm). Almost all significant variables were consistent between the two cohorts in both magnitude of association with CIMT and statistical significance, including age, sex, smoking, diabetes, cholesterol levels, and blood pressure. For example, the association with systolic blood pressure was (ΔSD = 0.011; 95% confidence interval, 0.0009 to 0.014) per mm Hg in MESA and (ΔSD = 0.010; 95% confidence interval, 0.005 to 0.021) per mm Hg in HNR. This consistency persisted throughout the traditional (Framingham) risk factors. Conclusions: A comparison of the associations between traditional cardiovascular risk factors and CIMT across two culturally diverse populations showed remarkable consistency.

J Am Soc Echocardiogr: 23 Apr 2013; epub ahead of print
Bauer M, Delaney JA, Möhlenkamp S, Jöckel KH, ... McClelland RL, Multi-Ethnic Study of Atherosclerosis and the Investigator Group of the Heinz Nixdorf Recall Study
J Am Soc Echocardiogr: 23 Apr 2013; epub ahead of print | PMID: 23611058
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Abstract

Increased Aortic Pulse Wave Velocity as Measured by Echocardiography Is Strongly Associated with Poor Prognosis in Patients with Heart Failure.

Bonapace S, Rossi A, Cicoira M, Targher G, ... Benetos A, Vassanelli C
Background: An increased aortic pulse wave velocity (PWV), a marker of arterial stiffness, is associated with poor prognosis in various diseases. In patients with heart failure (HF), an increased aortic PWV is associated with low peak exercise oxygen consumption, which is a strong risk factor of adverse clinical outcomes. However, it remains unknown if an increased aortic PWV predicts poor prognosis in patients with HF, independent of peak exercise oxygen consumption. Methods and results: We enrolled 156 patients with HF and left ventricular ejection fraction <45%, who were followed up for a mean (SD) period of 36 ± 19 months. At baseline, all the patients underwent a complete echocardiography with aortic PWV as measured by Doppler ultrasonography and peak exercise oxygen consumption as measured by bicycle exercise testing with expiratory gas exchange monitoring. During the follow-up period, 20 patients (12.8%) died and 15 patients (9.6%) were hospitalized for worsening HF. In the Kaplan-Meier analysis, patients in the first tertile of aortic PWV had a lower risk of developing cardiac death or hospitalization (combined end point) than those in the second and third tertile combined (P < .001). In Cox regression analysis, increased aortic PWV (both as a continuous and categorical variable) was significantly associated with an increased risk of adverse clinical outcomes after adjustment for peak exercise oxygen consumption and other clinical risk factors (P < .05). Conclusions: Increased aortic PWV, as measured by echocardiography, independently predicted adverse clinical outcomes (cardiac death or hospitalization) among patients with HF.

J Am Soc Echocardiogr: 15 May 2013; epub ahead of print
Bonapace S, Rossi A, Cicoira M, Targher G, ... Benetos A, Vassanelli C
J Am Soc Echocardiogr: 15 May 2013; epub ahead of print | PMID: 23676208
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Abstract

Left Ventricular False Tendons: Anatomic, Echocardiographic and Pathophysiologic Insights.

Silbiger JJ
Left ventricular (LV) false tendons are chordlike structures that traverse the LV cavity. They attach to the septum, to the papillary muscles, or to the free wall of the ventricle but not to the mitral valve. They are found in approximately half of human hearts examined at autopsy. Although it has been more than 100 years since their initial description, the functional significance of these structures remains largely unexplored. It has been suggested that they retard LV remodeling by tethering the walls to which they are attached, but there are few data to substantiate this. Some studies have suggested that false tendons reduce the severity of functional mitral regurgitation by stabilizing the position of the papillary muscles as the left ventricle enlarges. LV false tendons may also have deleterious effects and have been implicated in promoting membrane formation in discrete subaortic stenosis. This article reviews current understanding of the anatomy, echocardiographic characteristics, and pathophysiology of these structures.

J Am Soc Echocardiogr: 21 Apr 2013; epub ahead of print
Silbiger JJ
J Am Soc Echocardiogr: 21 Apr 2013; epub ahead of print | PMID: 23602169
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Standard and Advanced Echocardiography in Takotsubo (Stress) Cardiomyopathy: Clinical and Prognostic Implications.

Citro R, Lyon AR, Meimoun P, Omerovic E, ... Prasad A, Bossone E
Echocardiography is frequently the initial noninvasive imaging modality used to assess patients with takotsubo cardiomyopathy (TTC). Standard transthoracic echocardiography can provide, even in the acute care setting, useful information about left ventricular (LV) morphology as well as regional and global systolic or diastolic function. It allows the differentiation of different LV morphologic patterns according to the localization of wall motion abnormalities. A "circumferential pattern" of LV myocardial dysfunction characterized by symmetric wall motion abnormalities involving the midventricular segments of the anterior, inferior, and lateral walls should be considered suggestive of TTC and included in the differential diagnosis of acute coronary syndromes. Moreover, advanced echocardiographic techniques, including speckle-tracking, myocardial contrast, and coronary flow studies, are providing mechanistic and pathophysiologic insights into this unique syndrome. Early identification of any potential complications (i.e., LV outflow tract obstruction, reversible moderate to severe mitral regurgitation, right ventricular involvement, thrombus formation, and cardiac rupture) are crucial for the management, risk stratification, and follow-up of patients with TTC. Because of the dynamic evolution of the syndrome, comprehensive serial echocardiographic examinations should be systematically performed. This review focuses on these aspects of imaging and the increasing understanding of the clinical and prognostic utility of echocardiography in TTC.

J Am Soc Echocardiogr: 04 Oct 2014; epub ahead of print
Citro R, Lyon AR, Meimoun P, Omerovic E, ... Prasad A, Bossone E
J Am Soc Echocardiogr: 04 Oct 2014; epub ahead of print | PMID: 25282664
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Abstract

Decremental Left Ventricular Deformation after Pulmonary Artery Band Training and Subsequent Repair in Ventriculoarterial Discordance.

Sun HY, Behzadian F, Punn R, Tacy TA
Background: Patients with ventriculoarterial discordance, such as congenitally corrected and d-transposition of the great arteries, may undergo a morphologic left ventricular (LV) training strategy consisting of surgical pulmonary artery band (PAB) placement and subsequent anatomic repair to establish ventriculoarterial concordance. The purpose of this study was to characterize morphologic LV function and deformation longitudinally using speckle-tracking strain analysis in patients with ventriculoarterial discordance who underwent LV training. Methods: Twenty-nine patients (12 with d-transposition of the great arteries and 17 with congenitally corrected transposition of the great arteries) who underwent LV training with PAB placement were evaluated retrospectively. LV ejection fraction and global and regional longitudinal strain and strain rate were measured before and 7 ± 5 days after PAB placement and subsequent anatomic repair. Results: PAB placement caused reductions in the mean LV ejection fraction from 76.1 ± 10.2% to 66.7 ± 7.8% (P < .001), in mean global strain from -17.7 ± 9% to -13.3 ± 7.5% (P = .01), and in mean lateral wall strain from -23.3 ± 12.8% to -17.5 ± 10.3% (P = .01). After anatomic repair (a median of 21 months after PAB placement; range, 0.5-104 months), mean LV ejection fraction decreased further from 63.3 ± 8.6% to 52.4 ± 14.9% (P < .05). Mean global strain declined from -17.6% ± 4.4 to -12.6 ± 4% (P = .01), and mean lateral wall strain decreased from -18.2 ± 11.4% to -12.6 ± 5.3% (P = .04). Conclusions: In patients with ventriculoarterial discordance undergoing PAB placement for LV training and anatomic repair, the morphologic left ventricle demonstrated decremental systolic function and global longitudinal deformation acutely. Frequent functional assessment is warranted to understand long-term myocardial mechanics in these patients.

J Am Soc Echocardiogr: 28 Apr 2013; epub ahead of print
Sun HY, Behzadian F, Punn R, Tacy TA
J Am Soc Echocardiogr: 28 Apr 2013; epub ahead of print | PMID: 23623593
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Abstract

Regional Difference of Microcirculation in Patients with Asymmetric Hypertrophic Cardiomyopathy: Transthoracic Doppler Coronary Flow Velocity Reserve Analysis.

Tesic M, Djordjevic-Dikic A, Beleslin B, Trifunovic D, ... Ostojic M, Vujisic-Tesic B
Objective: To evaluate, by noninvasive coronary flow velocity reserve (CFVR), whether patients with asymmetric hypertrophic cardiomyopathy (HC), with or without left ventricular outflow tract obstruction, demonstrate significant regional differences of CFVR. Methods: We evaluated 61 patients with HC (27 men; mean age 49 ± 16 years), including 20 patients with hypertrophic obstructive cardiomyopathy (HOCM) and 41 patients without obstruction (HCM). The control group included 20 age- and sex-matched subjects. Transthoracic Doppler echocardiography CFVR of the left anterior descending coronary artery (LAD) and the posterior descending coronary artery (PD) were performed, including calculation of relative CFVR as the ratio between CFVR LAD and CFVR PD. Results: Compared with the controls, all the patients with HC had lower CFVR LAD (2.12 ± 0.53 vs 3.34 ± 0.67; P < .001) and CFVR PD (2.29 ± 0.49 vs 3.21 ± 0.65; P < .001). CFVR LAD in HOCM group in comparison with the HCM group was significantly lower (1.93 ± 0.42 vs 2.22 ± 0.55; P = .047), due to higher basal diastolic coronary flow velocities (0.40 ± 0.09 vs 0.33 ± 0.07 m/sec; P = .002), with similar hyperemic diastolic flow velocities (0.71 ± 0.16 vs 0.76 ± 0.19 m/sec; P = .330), respectively. There was no significant difference in CFVR PD between patients with HOCM and those with HCM (2.33 ± 0.46 vs 2.27 ± 0.50; P = .636), respectively. Relative CFVR was lower in the HOCM group compared with the HCM group (0.84 ± 0.16 vs 0.98 ± 0.14; P = .001). By multivariable regression analysis, left ventricular outflow tract gradient was the independent predictor of CFVR LAD (B = -0.24; P = .008) and relative CFVR (B = -0.34; P = .016). Conclusions: CFVR LAD and relative CFVR were significantly lower in patients with HOCM compared with patients with HCM. Regional differences of CFVR are present only in patients with significant left ventricular outflow tract obstruction, which suggests that obstruction per se, by increasing wall stress in basal conditions, leads to higher basal diastolic coronary flow velocities and results in lower CFVR in LAD compared with PD.

J Am Soc Echocardiogr: 05 May 2013; epub ahead of print
Tesic M, Djordjevic-Dikic A, Beleslin B, Trifunovic D, ... Ostojic M, Vujisic-Tesic B
J Am Soc Echocardiogr: 05 May 2013; epub ahead of print | PMID: 23643850
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Abstract

In Patients with Post-Infarction Left Ventricular Dysfunction, How Does Impaired Basal Rotation Affect Chronic Ischemic Mitral Regurgitation?

Zito C, Cusmà-Piccione M, Oreto L, Tripepi S, ... Lentini S, Carerj S
Background: The aim of this study was to explore the contribution of left ventricular (LV) basal rotation to the mechanism of chronic ischemic mitral regurgitation (MR). Methods: Fifty-seven patients (52 men; mean age, 68.3 ± 11.8 years) with postinfarction LV dysfunction (defined as an ejection fraction ≤45%) were prospectively enrolled. Each invariably had functional MR. To assess MR degree, the effective regurgitant orifice area (EROA) was quantified by echocardiography using the proximal isovelocity surface area method. Furthermore, mitral valve deformation (valve tenting and annular function) and LV global (systolic and diastolic volumes, function, and sphericity) and local remodeling (displacement of papillary muscles, regional strain, and rotation by speckle-tracking) were assessed. The patients were subsequently subdivided into two groups according to the absence (group A) or presence (group B) on transthoracic echocardiography of infarct area in the inferior and/or posterior basal segments. Results: A larger EROA was found in group B than in group A (P = .034) and in subjects with asymmetric rather than symmetric tethering in either group (P = .036 and P = .040 for groups A and B, respectively). Basal radial (P = .009), circumferential (P = .042), and longitudinal (P = .005) strain and rotation (P = .021) were lower in group B than in group A. There was also a significant inverse correlation between EROA and basal rotation in group B (r = -0.75, P < .001). Furthermore, using multivariate linear regression analysis, we found that the independent determinants of EROA were end-diastolic volume (P < .001) and tenting area (P = .004) in group A and asymmetric tethering (P = .029) and basal rotation (P < .001) in group B. Conclusions: Impaired basal rotational mechanics occurring after an inferior-posterior myocardial infarction is associated with increased MR.

J Am Soc Echocardiogr: 02 Jun 2013; epub ahead of print
Zito C, Cusmà-Piccione M, Oreto L, Tripepi S, ... Lentini S, Carerj S
J Am Soc Echocardiogr: 02 Jun 2013; epub ahead of print | PMID: 23727114
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Abstract

The Assessment of Atrial Function in Single Ventricle Hearts from Birth to Fontan: A Speckle-Tracking Study by Using Strain and Strain Rate.

Khoo NS, Smallhorn JF, Kaneko S, Kutty S, Altamirano L, Tham EB
Background: Single ventricle (SV) exercise performance is impaired and limited by reduced ventricular preload reserve. The atrium modulates ventricular filling, and enhancement of atrial compliance can increase cardiac performance. We aimed to study atrial mechanics in SV hearts across staged surgical palliation compared with healthy children by using novel speckle-tracking echocardiography techniques. Methods: A cross-sectional study of 81 patients with SV (1 day to 6.5 years) at 4 stages of surgical palliation (presurgery, 22; prebidirectional cavopulmonary anastomosis, 23; pre-Fontan, 22; post-Fontan, 14). The dominant atrium was assessed with speckle-tracking echocardiography for active (εact), conduit (εcon), and reservoir (εres) strain; strain rate (SR); and εact/εres ratio before each stage of surgical palliation. Findings were compared with the left atrium of 51 healthy children (1 day to 5.5 years). Results: Single ventricle atrial size was increased (P < .01), and atrial εres was decreased (P < .01) compared with healthy controls. SV atrial εcon (P < .01) and SRcon (P < .0001) was decreased, increased εact persisted (P < .05), and εact/εres was increased (P < .001) between surgical stages. Although the expected maturational trend of increasing εcon, decreasing εact, and εact/εres occurred in SV, they lagged behind healthy maturational changes (P < .0001). Conclusion: Single ventricle atrium is dilated, has deceased compliance, decreased early diastolic emptying, and increased reliance on active atrial contraction for ventricular filling. This deviates from normal early childhood maturational changes and appears to parallel those of an atrium facing early ventricular diastolic dysfunction.

J Am Soc Echocardiogr: 13 May 2013; epub ahead of print
Khoo NS, Smallhorn JF, Kaneko S, Kutty S, Altamirano L, Tham EB
J Am Soc Echocardiogr: 13 May 2013; epub ahead of print | PMID: 23669597
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Three-Dimensional Modeling of the Right Ventricle from Two-Dimensional Transthoracic Echocardiographic Images: Utility of Knowledge-Based Reconstruction in Pulmonary Arterial Hypertension.

Bhave NM, Patel AR, Weinert L, Yamat M, ... Gomberg-Maitland M, Lang RM
Background: Right ventricular (RV) volume and functional assessments are essential in the management of pulmonary arterial hypertension but are often difficult to perform. Three-dimensional (3D) echocardiography is limited by acoustic dropout of the RV free wall in dilated ventricles. The aim of this study was to test the hypothesis that knowledge-based reconstruction, a novel method for 3D modeling of RV endocardium from two-dimensional echocardiographic images, could provide accurate measurements of RV volumes and systolic function. Methods: Twenty-seven patients with pulmonary arterial hypertension were prospectively recruited for same-day echocardiography and cardiovascular magnetic resonance (CMR), which was used as a reference standard. Two-dimensional transthoracic echocardiographic images were acquired with 3D spatial localization equipment to allow 3D reconstruction. Image analysis was performed with dedicated software to obtain end-diastolic volume (EDV) and end-systolic volume (ESV) and RV ejection fraction (EF). The method of disks was used to determine RV volumes on CMR. Results: Echocardiographic RV volumes correlated well with CMR (EDV, R = 0.87; ESV, R = 0.88; EF, R = 0.75). For interobserver analyses, coefficients of variability were 7.8 ± 7.0% for EDV, 10.2 ± 8.0% for ESV, and 15.4 ± 13.8% for EF. For intraobserver analyses, coefficients of variability were 7.1 ± 5.1% for EDV, 8.3 ± 7.0% for ESV, and 10.9 ± 9.2% for EF. On Bland-Altman analyses, volumes obtained on transthoracic echocardiography (TTE) were slightly larger than those obtained by CMR (ΔEDVTTE-CMR, 5.8 ± 33.7 mL; ΔESVTTE-CMR, 3.5 ± 27.8 mL), whereas EFs tended to be slightly higher by CMR (ΔEFCMR-TTE, 0.5 ± 6.5%). Conclusions: Knowledge-based reconstruction provides accurate and reproducible measurements of RV volumes in patients with pulmonary arterial hypertension. Larger studies are needed to confirm these results and to determine the practicality of this approach in daily practice and as an end point in clinical trials.

J Am Soc Echocardiogr: 16 Jun 2013; epub ahead of print
Bhave NM, Patel AR, Weinert L, Yamat M, ... Gomberg-Maitland M, Lang RM
J Am Soc Echocardiogr: 16 Jun 2013; epub ahead of print | PMID: 23768691
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Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the american society of echocardiography and the European association of cardiovascular imaging.

Lang RM, Badano LP, Mor-Avi V, Afilalo J, ... Tsang W, Voigt JU
The rapid technological developments of the past decade and the changes in echocardiographic practice brought about by these developments have resulted in the need for updated recommendations to the previously published guidelines for cardiac chamber quantification, which was the goal of the joint writing group assembled by the American Society of Echocardiography and the European Association of Cardiovascular Imaging. This document provides updated normal values for all four cardiac chambers, including three-dimensional echocardiography and myocardial deformation, when possible, on the basis of considerably larger numbers of normal subjects, compiled from multiple databases. In addition, this document attempts to eliminate several minor discrepancies that existed between previously published guidelines.

J Am Soc Echocardiogr: 05 Jan 2015; 28:1-39.e14
Lang RM, Badano LP, Mor-Avi V, Afilalo J, ... Tsang W, Voigt JU
J Am Soc Echocardiogr: 05 Jan 2015; 28:1-39.e14 | PMID: 25559473
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Abstract

Experts and Beginners Benefit from Three-Dimensional Echocardiography: A Multicenter Study on the Assessment of Mitral Valve Prolapse.

Hien MD, Großgasteiger M, Rauch H, Weymann A, Bekeredjian R, Rosendal C
Background: Three-dimensional (3D) transesophageal echocardiography (TEE) has been claimed to provide more information than two-dimensional (2D) TEE in the localization of mitral valve prolapse (MVP). However, most studies have been performed by experts in echocardiography, without accounting for differences in training or expertise. This multicenter study was designed to assess the differences between experts and inexperienced echocardiographers in localizing MVP and ruptured chordae tendineae using 2D and real-time 3D TEE. Methods: Thirty-six observers from 10 institutions in Germany and Switzerland interpreted 2D and 3D transesophageal echocardiographic images from six patients selected to represent a large spectrum of MVP diversity. Surgical findings served as a reference. Individual performance in the prediction of pathology was scored. Differences between 15 experts and 21 beginners in TEE were assessed, and the benefits conferred by 3D TEE were compared. Results: Both study groups scored significantly higher when interpreting 3D transesophageal echocardiographic images (P ≤ .001). The experts were superior in 2D MVP localization (14.8%; P ≤ .001), a difference that diminished with 3D TEE (1.4%; P = .41). The benefit of access to 3D information for MVP localization was greater for inexperienced echocardiographers compared with experts (P < .001). Conclusions: The reported diagnostic advantage of 3D TEE over 2D TEE in MVP assessment for expert echocardiographers can be transferred to inexperienced echocardiographers. Inexperienced echocardiographers benefit from the technology to a greater extent than their expert colleagues.

J Am Soc Echocardiogr: 26 May 2013; epub ahead of print
Hien MD, Großgasteiger M, Rauch H, Weymann A, Bekeredjian R, Rosendal C
J Am Soc Echocardiogr: 26 May 2013; epub ahead of print | PMID: 23706343
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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.

Lancellotti P, Nkomo VT, Badano LP, Bergler J, ... Society for Cardiovascular Magnetic Resonance, and Society of Cardiovascular Computed Tomography
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.

J Am Soc Echocardiogr: 02 Sep 2013; 26:1013-32
Lancellotti P, Nkomo VT, Badano LP, Bergler J, ... Society for Cardiovascular Magnetic Resonance, and Society of Cardiovascular Computed Tomography
J Am Soc Echocardiogr: 02 Sep 2013; 26:1013-32 | PMID: 23998694
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Abstract

Right Ventricular Regional Systolic Function and Dyssynchrony in Patients with Pulmonary Hypertension Evaluated by Three-Dimensional Echocardiography.

Kong D, Shu X, Dong L, Pan C, ... Yao H, Zhou D
Background: The aim of this study was to evaluate right ventricular (RV) regional systolic function and dyssynchrony in patients with pulmonary hypertension (PH) using real-time three-dimensional echocardiography. Methods: Real-time three-dimensional echocardiographic images were acquired to obtain RV regional (inflow, body, and outflow) ejection fraction (EF) and time to minimum systolic volume in 70 patients with PH and 26 normal controls. Pulmonary artery systolic pressure (PASP) and pulmonary vascular resistance measured by echocardiography in all subjects and by right heart catheterization in 17 patients were recorded. Results: Inflow EF and global EF were significantly lower in patients with PH than in controls (P < .05). Body EF was significantly decreased in patients with moderate (PASP, 50-69mm Hg) and severe (PASP ≥ 70 mm Hg) PH (P < .05). Outflow EF was significantly lowered in patients with severe PH (P < .001). The standard deviation of regional time to minimum systolic volume corrected by heart rate was significantly prolonged in patients with severe PH (P < .05). Inflow EF and global EF were negatively correlated with PASP (r = -0.731 and r = -0.769, respectively, P < .001) and with pulmonary vascular resistance (r = -0.789 and r = -0.801, P < .001). Conclusions: In patients with PH, RV inflow and global systolic function was impaired in inverse relationship with PASP and pulmonary vascular resistance. RV systolic synchronicity was impaired in patients with severe PH. Evaluation of RV regional systolic function using real-time three-dimensional echocardiography may play a potential role in the noninvasive assessment of the severity of PH.

J Am Soc Echocardiogr: 28 Apr 2013; epub ahead of print
Kong D, Shu X, Dong L, Pan C, ... Yao H, Zhou D
J Am Soc Echocardiogr: 28 Apr 2013; epub ahead of print | PMID: 23622884
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Abstract

Impact of Propofol Anesthesia Induction on Cardiac Function in Low-Risk Patients as Measured by Intraoperative Doppler Tissue Imaging.

Yang HS, Song BG, Kim JY, Kim SN, Kim TY
Background: Despite a few experimental studies showing a dose-dependent myocardial depressive effect of propofol anesthesia induction, few clinical data are available to determine its precise impact on myocardial function, probably because of its brevity and a lack of appropriate evaluation tools. The purpose of this study was to examine the impact of propofol-based anesthesia induction on left ventricular (LV) function using Doppler tissue and speckle-tracking imaging. Methods: In 19 low-risk patients with normal LV systolic and diastolic function undergoing noncardiac surgery (all women; mean age, 42 years), propofol bolus (2.0 mg/kg) was administered intravenously for anesthesia induction. LV ejection fraction, global peak systolic longitudinal strain, and tissue Doppler-derived indices of mitral annular velocity during systole (S\'), early diastole (e\'), and atrial contraction (a\') were determined by intraoperative transthoracic echocardiography before and 1, 3, and 5 min after propofol bolus (T0, T1, T2, and T3, respectively). Results: The following at T1, T2, and T3 were significantly less in magnitude than at T0: septal S\' (5.61, 5.61, and 5.51 vs 7.60 cm/sec, P < .001), lateral S\' (5.75, 5.89, and 5.94 vs 8.12 cm/sec, P < .001), septal e\' (10.10, 10.26, and 10.07 vs 11.4 cm/sec, P < .01), septal a\' (6.70, 6.21, and 6.13 vs 8.58 cm/sec, P < .01), lateral a\' (7.29, 6.81, and 6.85 vs 9.01 cm/sec, P < .01), and longitudinal strain (-19.36%, -19.71%, and -19.61% vs -22.28%, P < .001). LV ejection fraction was not significantly changed (P = .361). Conclusions: Propofol anesthesia induction diminished LV and atrial contraction in low-risk patients with prior normal LV function. Further studies are needed to understand the clinical implications, particularly for higher risk populations.

J Am Soc Echocardiogr: 28 Apr 2013; epub ahead of print
Yang HS, Song BG, Kim JY, Kim SN, Kim TY
J Am Soc Echocardiogr: 28 Apr 2013; epub ahead of print | PMID: 23622885
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Abstract

Comparison of Echocardiographic Measurements of Left Ventricular Volumes to Full Volume Magnetic Resonance Imaging in Normal and Diseased Rats.

Arias T, Chen J, Fayad ZA, Fuster V, Hajjar RJ, Chemaly ER
Background: Clinical two-dimensional (2D) and clinical three-dimensional echocardiography are validated against cardiac magnetic resonance imaging (CMR), the gold standard for left ventricular (LV) volume measurement. In rodents, there is no widely accepted echocardiographic measure of whole LV volumes, and CMR measurements vary among studies. The aim of this study was to compare LV volumes by 2D echocardiography (using a hemisphere-cylinder [HC] model) with HC and full-volume (FV) CMR in normal and diseased rats to measure the impact of geometric models and imaging modalities. Methods: Rats (n = 27) underwent ascending aortic banding, myocardial infarction induction by either permanent left anterior descending coronary artery ligation or ischemia-reperfusion, and sham thoracotomy. Subsequently, end-diastolic volume, end-systolic volume, and ejection fraction were measured using an HC 2D echocardiographic model combining parasternal short-axis and long-axis measurements, and these were compared with HC and FV CMR. Results: Diseased groups showed LV dilatation and dysfunction. HC echocardiographic and FV CMR measures of end-diastolic volume, end-systolic volume, and ejection fraction were correlated. On Bland-Altman plots, end-diastolic volumes were concordant between both methods, while HC echocardiography underestimated end-systolic volumes, resulting in a modest overestimation of ejection fractions compared with FV CMR. Other 2D echocardiographic geometric models offered less concordance with FV CMR than HC. HC CMR overestimated LV volumes compared with FV CMR, while HC echocardiography underestimated HC CMR volumes. Echocardiography underestimated corresponding LV dimensions by CMR, particularly short axis. Conclusions: Concordant measures of LV volume and function were obtained using (1) a relatively simple HC model of the left ventricle inclusive of two orthogonal 2D echocardiographic planes and (2) FV CMR in normal and diseased rats. The HC model appeared to compensate for the underestimation of LV dimensions by echocardiography.

J Am Soc Echocardiogr: 26 May 2013; epub ahead of print
Arias T, Chen J, Fayad ZA, Fuster V, Hajjar RJ, Chemaly ER
J Am Soc Echocardiogr: 26 May 2013; epub ahead of print | PMID: 23706342
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Abstract

Mitral Valve Dynamics in Severe Aortic Stenosis before and after Aortic Valve Replacement.

Tsang W, Veronesi F, Sugeng L, Weinert L, ... Jeevanandam V, Lang RM
Background: The aortic and mitral valves are anatomically linked through a fibrous continuity. The investigators hypothesized that severe aortic stenosis (AS) would alter this fibrous continuity, affecting both the mitral valve and left ventricular function, and that mitral valve function would be altered after aortic valve replacement (AVR). The aim of this study was to evaluate the impact of AS and its treatment with surgical AVR on the mitral valve. Methods: Three-dimensional transesophageal echocardiography (using a Philips iE33 system) was performed on 49 patients: 20 controls with normal valves and left ventricular function, 20 with AS and normal left ventricular function studied before and after AVR, and nine with systolic heart failure and normal valves. Custom software tracked the aortic and mitral valves in three-dimensional space, allowing automated measurements of aortic and mitral annular (MA) morphology throughout the cardiac cycle. Results: Patients with AS before AVR had reduced MA velocities. After AVR, aortic and MA areas were significantly smaller throughout the cardiac cycle compared with controls and pre-AVR values. MA displacement was reduced after AVR and in patients with systolic heart failure compared with those with AS and controls. Conclusions: Dynamic MA function is changed with AS and after AVR through alterations in the aortic-mitral fibrous continuity. The prosthetic valve ring results in reduced aortic and MA areas, which could affect blood flow in and out of the left ventricle. These changes suggest that the design of future prosthetic aortic valves should be more flexible to preserve the function of the aortic-mitral fibrous continuity.

J Am Soc Echocardiogr: 21 Apr 2013; epub ahead of print
Tsang W, Veronesi F, Sugeng L, Weinert L, ... Jeevanandam V, Lang RM
J Am Soc Echocardiogr: 21 Apr 2013; epub ahead of print | PMID: 23602168
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Abstract

New Three-Dimensional Speckle-Tracking Echocardiography Identifies Global Impairment of Left Ventricular Mechanics with a High Sensitivity in Childhood Cancer Survivors.

Yu HK, Yu W, Cheuk DK, Wong SJ, Chan GC, Cheung YF
Background: The aim of this case-control study was to assess the usefulness of three-dimensional (3D) speckle-tracking echocardiography in the evaluation of global left ventricular (LV) myocardial performance in adolescent and adult survivors of childhood cancers. Methods: Fifty-three anthracycline-treated survivors of childhood cancers (mean age, 18.6 ± 5.1 years) and 38 controls were studied. Three-dimensional speckle-tracking echocardiography was performed to assess LV 3D global and segmental strain, time to peak segmental 3D strain, LV torsion, and ejection fraction. LV systolic dyssynchrony index (SDI) was calculated as the percentage of the standard deviation of times to peak strain of the 16 segments divided by the RR interval. A global performance index (GPI) was calculated as (global 3D strain × torsion)/SDI. The area under the receiver operating characteristic curve was calculated to determine the capability of various echocardiographic indices to discriminate between patients and controls. Results: Compared with controls, patients had significantly reduced LV global 3D strain (P < .001), torsion (P < .001), and GPI (P < .001) and greater SDI (P < .001). All except the basal anteroseptal segment in patients had reduced regional 3D strain compared with controls (P < .05 for all). Global 3D strain (P = .018), SDI (P = .003), and GPI (P = .02) were correlated with cumulative anthracycline dose. The areas under the curves for GPI, global 3D strain, 1/SDI, torsion, and ejection fraction were 0.92, 0.79, 0.79, 0.79, and 0.78, respectively. A GPI cutoff of 10.6°/cm had sensitivity of 84.9% and specificity of 81.6% of differentiating patients from controls. Conclusions: Three-dimensional speckle-tracking echocardiography enables the derivation of an index of LV global performance that incorporates LV 3D strain, dyssynchrony, and torsion for the sensitive detection of altered LV mechanics in childhood cancer survivors.

J Am Soc Echocardiogr: 02 Jun 2013; epub ahead of print
Yu HK, Yu W, Cheuk DK, Wong SJ, Chan GC, Cheung YF
J Am Soc Echocardiogr: 02 Jun 2013; epub ahead of print | PMID: 23727115
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Abstract

Three-Dimensional Transesophageal Echocardiographic Evaluation of Coronary Involvement in Patients with Acute Type A Aortic Dissection.

Sasaki S, Watanabe H, Shibayama K, Mahara K, ... Sumiyoshi T, Tomoike H
Background: Acute Stanford type A aortic dissection (AAD) with coronary involvement is associated with high mortality. However, coronary involvement is not always successfully visualized by computed tomography and two-dimensional (2D) transesophageal echocardiography (TEE). The aim of this study was to test the hypothesis that three-dimensional (3D) TEE can detect coronary involvement in patients with AAD. Methods: Fifty-one consecutive patients with AAD who underwent intraoperative TEE using an iE33 system during emergency surgery were enrolled. Using computed tomographic images, conventional 2D transesophageal echocardiographic images, and a 3D transesophageal echocardiographic data set, the status of coronary ostia was evaluated and classified into four types-branching from true lumen, branching from false lumen, dissection, and unclear-and these results were compared with operative findings. Results: In six patients, coronary involvement was diagnosed operatively by surgeons. They comprised dissection at three left coronary ostia and branching from false lumen at three right coronary ostia. All six cases were successfully detected by both 2D TEE and 3D TEE before instituting cardiopulmonary bypass. However, in 45 patients (90 ostia) confirmed operatively as having no coronary involvement, 69 ostia by computed tomography (36 in the left and 33 in the right coronary artery) and 16 ostia by 2D TEE (four in the left and 12 in the right coronary artery) were evaluated as unclear coronary involvement. On the other hand, 3D TEE clearly depicted no coronary involvement in all but one (right coronary ostium) of the unclear cases. Conclusions: Three-dimensional TEE reduced the number of cases evaluated as unclear coronary involvement by computed tomography and 2D TEE. In patients with AAD, 3D TEE allows evaluation of the status of coronary ostia in the operating room.

J Am Soc Echocardiogr: 12 Jun 2013; epub ahead of print
Sasaki S, Watanabe H, Shibayama K, Mahara K, ... Sumiyoshi T, Tomoike H
J Am Soc Echocardiogr: 12 Jun 2013; epub ahead of print | PMID: 23759167
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Abstract

Comprehensive Echocardiographic Assessment of Mechanical Tricuspid Valve Prostheses Based on Early Post-Implantation Echocardiographic Studies.

Blauwet LA, Burkhart HM, Dearani JA, Malouf JF, ... Herges RM, Miller FA
Background: Doppler-derived hemodynamic data for normal tricuspid mechanical valve prostheses are limited. Methods: A comprehensive retrospective Doppler echocardiographic assessment of 78 normal St. Jude Medical Standard (St. Jude Medical, Inc., St. Paul, MN), CarboMedics Standard (CarboMedics, Inc., Sorin Group, Burnaby, British Columbia, Canada), and Starr-Edwards (Edwards Lifesciences, LLC, Irvine, CA) mechanical tricuspid valve prostheses was performed early after implantation. We used all the important Doppler-derived hemodynamic variables reported to date, including peak early diastolic velocity (E velocity), mean gradient, pressure half-time, time velocity integral of the tricuspid valve prosthesis (TVI(TVP)), and ratio of the time velocity integral of the tricuspid valve prosthesis to the time velocity integral of the left ventricular outflow tract (TVI(TVP)/TVI(LVOT)). Results: The mean values obtained for the Doppler parameters did not differ significantly when the measurements from five or nine consecutive cardiac cycles were averaged. Pressure half-time was <130 msec in all 43 patients with St. Jude Medical Standard and CardioMedics Standard prostheses in whom it could be measured. Mean gradient <6 mm Hg, E velocity <1.9 m/s, TVI(TVP) <46 cm, and TVI(TVP)/TVI(LVOT) <2.1 were recorded in 59 (87%) of the 68 patients with either of these prostheses. Hemodynamic variables were considerably less favorable in patients with Starr-Edwards prostheses. Conclusion: These calculated threshold values (mean + 2 SD) are useful for identifying normal tricuspid mechanical valve function. Prostheses with values for hemodynamic variables that are outside the mean + 2 SD parameters that we have calculated are most likely to be dysfunctional. However, in rare cases, mechanical tricuspid valve prostheses may be dysfunctional even when their hemodynamic parameters are within these specified ranges because of small body surface area or other factors.

J Am Soc Echocardiogr: 19 Jan 2011; epub ahead of print
Blauwet LA, Burkhart HM, Dearani JA, Malouf JF, ... Herges RM, Miller FA
J Am Soc Echocardiogr: 19 Jan 2011; epub ahead of print | PMID: 21244867
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Abstract

Tissue-Doppler Assessment of Cardiac Left Ventricular Function during Short-Term Adjuvant Epirubicin Therapy for Breast Cancer.

Appel JM, Sogaard P, Mortensen CE, Skagen K, Nielsen DL
Background: It has been hypothesized that the extent of acute anthracycline-induced cardiotoxicity reflects the risk for late development of heart failure. The aim of this study was to examine if short-term changes in cardiac function can be detected even after low-dose adjuvant epirubicin therapy for breast cancer when using Doppler tissue imaging of longitudinal left ventricular function. Methods: Eighty consecutive women in good cardiopulmonary health scheduled to undergo adjuvant treatment for breast cancer were included. They were examined using echocardiography and Doppler tissue imaging before and after three treatment series of epirubicin (mean cumulative dose, 273.7 ± 46.6 mg/m(2); median time interval, 9 weeks; range, 47-113 days). Results: Apart from a marginal reduction in E/A ratio, none of the conventional Doppler echocardiographic or Doppler tissue imaging indices of systolic and diastolic function were affected during epirubicin treatment. Conclusions: In contrast to several previous studies using tissue Doppler and conventional echocardiography, this study did not document relevant short-term effects of low-dose epirubicin treatment on heart function.

J Am Soc Echocardiogr: 13 Jan 2011; epub ahead of print
Appel JM, Sogaard P, Mortensen CE, Skagen K, Nielsen DL
J Am Soc Echocardiogr: 13 Jan 2011; epub ahead of print | PMID: 21227647
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Abstract

Feasibility of Intraoperative Three-Dimensional Transesophageal Echocardiography in the Evaluation of Right Ventricular Volumes and Function in Patients Undergoing Cardiac Surgery.

Fusini L, Tamborini G, Gripari P, Maffessanti F, ... Fiorentini C, Pepi M
Background: The aim of this study was to test the feasibility of the assessment of right ventricular (RV) volumes and function using real-time three-dimensional (3D) transesophageal echocardiographic (TEE) imaging in patients undergoing cardiac surgery. Methods: One hundred-fifty surgical patients were enrolled: 65 undergoing mitral valve repair, 10 undergoing mitral valve and tricuspid valve repair, four with congenital heart disease, two undergoing Jarvik implantation, 13 undergoing aortic valve surgical replacement, and 56 undergoing transcatheter aortic valve implantation. Real-time 3D TEE acquisition for RV evaluation was performed before and after the surgical procedure and compared with standard two-dimensional multiplane TEE measurements. In a subgroup of 81 patients, 3D transthoracic echocardiographic imaging was also performed. RV volumetric quantification was performed for all data using dedicated software. Results: Three-dimensional RV analysis was feasible in 98.7% in the preoperative TEE data set and in 92.7% in the postoperative TEE data set. Agreement between 3D transthoracic and transesophageal echocardiography for end-diastolic volume (r = 0.98; 95% confidence interval [CI], -0.2 ± 13.6 mL), end-systolic volume (r = 0.97; 95% CI, -2.1 ± 10.2 mL), ejection fraction (r = 0.77; 95% CI, 1.8 ± 8.2%), and stroke volume (r = 0.91; 95% CI, 2.0 ± 12.9 mL) was significant. RV parameters were highly reproducible in patients with both normal and dilated RV volumes. Conclusions: Intraoperative 3D TEE assessment of RV volumes and function is feasible in patients with normal and dilated right ventricles, with good correlation between 3D transthoracic echocardiographic and TEE RV parameters. These measurements could improve the quantitative evaluation of RV function during cardiac surgery.

J Am Soc Echocardiogr: 13 Jun 2011; epub ahead of print
Fusini L, Tamborini G, Gripari P, Maffessanti F, ... Fiorentini C, Pepi M
J Am Soc Echocardiogr: 13 Jun 2011; epub ahead of print | PMID: 21665432
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Abstract

Patterns of Aortic Dilatation in Bicuspid Aortic Valve-Associated Aortopathy.

Khoo C, Cheung C, Jue J
Background: Bicuspid aortic valves (BAVs) are associated with aortopathy. Recent studies suggest that aortic dilatation is more likely to be seen with left-right coronary cusp fusion (type I) compared with right-noncoronary cusp fusion (type II). The aim of this study was to investigate the association between BAV morphology and patterns of aortopathy. Methods: Aortic dimensions and BAV morphology were obtained retrospectively from archived cine loops of 581 consecutive patients with BAVs and 277 matched normal controls from the Vancouver General Hospital echocardiography database. Patient demographics and other echocardiographic parameters were extracted from the database. Results: The study population was composed of 71% type I BAVs (415 patients) and 26% type II BAVs (149 patients). Aortic dilatation was present in 30% of the population. Type I BAV was associated with increased dimensions indexed to body surface area at the sinus of Valsalva compared with type II BAV. No difference in proximal ascending aortic dimension was seen between different BAV morphologies. The pattern of dilatation with type I BAV was more likely to be at the level of the annulus or sinus of Valsalva compared with type II BAV (62% vs 33%, P = .002). Type I BAV was an independent predictor of proximal aortic dilatation (odds ratio, 3.42; 95% confidence interval, 1.07-10.9). Conclusions: Type I BAV is associated with a greater likelihood of dilatation at the annulus and sinus of Valsalva. There is relative sparing of this region of the aorta in patients with type II BAVs. Individuals with different BAV morphologies may require different strategies of aortopathy surveillance.

J Am Soc Echocardiogr: 07 Apr 2013; epub ahead of print
Khoo C, Cheung C, Jue J
J Am Soc Echocardiogr: 07 Apr 2013; epub ahead of print | PMID: 23562085
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Abstract

Test-Retest Variability of Volumetric Right Ventricular Measurements Using Real-Time Three-Dimensional Echocardiography.

van der Zwaan HB, Geleijnse ML, Soliman OI, McGhie JS, ... Roos-Hesselink JW, Meijboom FJ
Background: Substantial variability in sequential echocardiographic right ventricular (RV) quantification may exist. Interobserver and intraobserver values are well known, but acquisition (test-retest) variability has been rarely assessed. The objective of this study was to determine the test-retest variability of sequential RV volume and ejection fraction (EF) measurements by real-time three-dimensional echocardiography in patients with congenital heart disease and healthy controls. Methods: Twenty-eight participants (21 patients with congenital heart disease, seven healthy controls; mean age, 30 ± 14 years; 43% men) underwent a series of three echocardiographic studies. To obtain interobserver and intraobserver test-retest variability, two sonographers acquired sequential RV data sets in each participant during one outpatient visit. RV volumetric quantification was done using semiautomated three-dimensional border detection. The variability data were analyzed using correlation coefficients, Bland-Altman analysis, and coefficients of variation. Results: Absolute mean differences for sequential intraobserver acquisitions were 12 ± 12 mL for end-diastolic volume, 7 ± 6 mL for end-systolic volume, and 4 ± 3% for EF. Interobserver and intraobserver test-retest variability, respectively, were 7% and 7% for RV end-diastolic volume, 14% and 7% for end-systolic volume, and 8% and 6% for EF. Conclusions: Good test-retest variability, besides the practical nature of real-time three-dimensional echocardiography for RV volume and EF assessment, makes it a valuable technique for serial follow-up. Although it may be challenging to diminish all factors that can influence echocardiographic examination for serial follow-up, standardization of RV size and functional measurements should be a goal to produce more interchangeable data.

J Am Soc Echocardiogr: 28 Mar 2011; epub ahead of print
van der Zwaan HB, Geleijnse ML, Soliman OI, McGhie JS, ... Roos-Hesselink JW, Meijboom FJ
J Am Soc Echocardiogr: 28 Mar 2011; epub ahead of print | PMID: 21440417
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Abstract

Diagnostic Value of Rigid Body Rotation in Noncompaction Cardiomyopathy.

van Dalen BM, Caliskan K, Soliman OI, Kauer F, ... Ten Cate FJ, Geleijnse ML
Background: The diagnosis of noncompaction cardiomyopathy (NCCM) remains subject to controversy. Because NCCM is probably caused by an intrauterine arrest of the myocardial fiber compaction during embryogenesis, it may be anticipated that the myocardial fiber helices, normally causing left ventricular (LV) twist, will also not develop properly. The resultant LV rigid body rotation (RBR) may strengthen the diagnosis of NCCM. The purpose of the current study was to explore the diagnostic value of RBR in a large group of patients with prominent trabeculations. Methods: The study comprised 15 patients with dilated cardiomyopathy, 52 healthy subjects, and 52 patients with prominent trabeculations, of whom a clinical expert in NCCM defined 34 as having NCCM. LV rotation patterns were determined by speckle-tracking echocardiography and defined as follows: pattern 1A, completely normal rotation (initial counterclockwise basal and clockwise apical rotation, followed by end-systolic clockwise basal and counterclockwise apical rotation); pattern 1B, partly normal rotation (normal end-systolic rotation but absence of initial rotation in the other direction); and pattern 2, RBR (rotation at the basal and apical level predominantly in the same direction). Results: The majority of normal subjects had LV rotation pattern 1A (98%), whereas the 18 subjects with hypertrabeculation not fulfilling diagnostic criteria for NCCM predominantly had pattern 1B (71%), and the 34 patients with NCCM predominantly had pattern 2 (88%). None of the patients with dilated cardiomyopathy showed RBR. Sensitivity and specificity of RBR for differentiating NCCM from "hypertrabeculation" were 88% and 78%, respectively. Conclusions: RBR is an objective, quantitative, and reproducible functional criterion with good predictive value for the diagnosis of NCCM as determined by expert opinion.

J Am Soc Echocardiogr: 24 Feb 2011; epub ahead of print
van Dalen BM, Caliskan K, Soliman OI, Kauer F, ... Ten Cate FJ, Geleijnse ML
J Am Soc Echocardiogr: 24 Feb 2011; epub ahead of print | PMID: 21345651
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