Vletter, W.B.

Diastolic abnormalities in normal phenotype hypertrophic cardiomyopathy gene carriers: A study using speckle tracking echocardiography (Article)

2013-05-01T00:00:00Z

Background Tissue Doppler imaging (TDI) of the mitral annulus has been proposed as an alternative for the identification of hypertrophic cardiomyopathy (HCM) genetically affected subjects without left ventricular hypertrophy (G+/LVH-). Unfortunately, conflicting results have been described in the literature, potentially caused by the angle-dependency of TDI. This study sought to assess abnormalities in mitral annular velocities in G+/LVH- subjects as detected by speckle tracking echocardiography (STE). Methods The study population consisted of 23 consecutive genotyped family members without major or minor criteria for the diagnosis of HCM (mean age 37 ± 13 years, 9 men) and 23 healthy volunteers (age 38 ± 12 years, 12 men) who prospectively underwent STE. Results There were no significant differences in global peak systolic annular velocity (7.4 ± 1.2 vs. 7.1 ± 1.0 cm/sec) and early diastolic annular velocity (10.2 ± 2.5 vs. 11.3 ± 2.2 cm/sec) between G+/LVH- and control subjects. Global peak late diastolic annular velocity was higher in G+/LVH- subjects (8.1 ± 1.7 vs. 5.7 ± 1.1 cm/sec, P < 0.001). Regionally, this difference was seen in all 6 studied LV walls. Conclusions This STE study confirms our previous TDI observations on increased peak late diastolic annular velocities in G+/LVH- subjects. Because of the complete overlap in early diastolic annular velocities this parameter cannot be used in the genotypes we studied to differentiate genotype (+) from genotype (-) individuals.

Regional left ventricular rotation and back-rotation in patients with reverse septal curvature hypertrophic cardiomyopathy (Article)

2013-05-01T00:00:00Z

AimsThis study sought to investigate regional left ventricular (LV) rotation in patients with hypertrophic cardiomyopathy (HCM).Methods and resultsThe study comprised 44 patients with HCM with a typical reverse septal curvature (age 40 ± 14 years, 33 men) and 44 healthy volunteers (age 39 ± 14 years, 32 men) in whom LV rotation could be assessed at the basal and apical LV level with speckle-tracking echocardiography, using the QLAB Advanced Quantification Software version 6.0 (Philips, Best, The Netherlands). In HCM patients, lower values of initial counter-clockwise rotation at the basal LV level (1.5 ± 1.2 vs. 0.6 ± 0.9°, P < 0.001) were seen, in particular in the septal segment (1.7 ± 1.6 vs. 0.4 ± 0.7°, P < 0.001). After this period, the direction of rotation changed to clockwise with a peak basal rotation of -4.8 ± 2.0° in controls vs. -6.1 ± 2.5° in HCM patients (P < 0.05). Peak basal rotation in HCM patients was in particular higher in the anterior (-6.6 ± 3.0 vs. -4.4 ± 2.4°, P < 0.01) and septal (-5.4 ± 2.6 vs. -3.9 ± 1.9°, P < 0.05) segments. The normalized (corrected for peak basal rotation) global back-rotation rate was lower in HCM patients (4.1 ± 3.1 vs. 6.3 ± 4.9 s-1, P < 0.05), in particular driven by a lower rate in the septal segment (3.8 ± 2.6 vs. 6.4 ± 4.8 s -1, P < 0.01). At the apical level, changes in rotation and back-rotation were more homogeneous.ConclusionChanges in rotation and back-rotation at the LV basal level in HCM patients are mainly caused by regional changes in the basal septal and anterior segments, the segments mostly involved in the hypertrophic process. © The Author 2012.

Assessment of Subendocardial Contractile Function in Aortic Stenosis: A Study Using Speckle Tracking Echocardiography (Article)

2013-01-28T00:00:00Z

Background: Angina and an electrocardiographic strain pattern are potential manifestations of subendocardial ischemia in aortic stenosis (AS). Left ventricular (LV) twist is known to increase proportionally to the severity of AS, which may be a result of loss of the inhibiting effect of the subendocardial fibers due to subendocardial dysfunction. It has also been shown that the ratio of LV twist to circumferential shortening of the endocardium (twist-to-shortening ratio [TSR]) is a reliable parameter of subendocardial dysfunction. The aim of this study was to investigate whether these markers are increased in AS patients with angina and/or electrocardiographic strain. Methods: The study comprised 60 AS patients with an aortic valve area <2.0 cm2and LV ejection fraction >50%, and 30 healthy-for age and gender matched-control subjects. LV rotation parameters were determined by speckle tracking echocardiography. Results: Comparison of patients without angina and strain (n = 22), with either angina or strain (n = 28), and with both angina and strain (n = 8), showed highest peak systolic LV apical rotation, peak systolic LV twist, and TSR, in patients with more signs of subendocardial ischemia. In a multivariate linear regression model, only severity of AS and the presence of angina and/or strain could be identified as independent predictors of peak systolic LV twist and TSR. Conclusions: Peak systolic LV twist and TSR are increased in AS patients and related to the severity of AS and symptoms (angina) or electrocardiographic signs (strain) compatible with subendocardial ischemia.

Diagnostic Value of Rigid Body Rotation in Noncompaction Cardiomyopathy (Article)

2011-05-01T00:00:00Z

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.

Contrast echocardiography improves interobserver agreement for wall motion score index and correlation with ejection fraction (Article)

2011-05-01T00:00:00Z

Background: The wall motion score index (WMSI) is a surrogate for left ventricular ejection fraction (LV-EF), which becomes unreliable in poor echo windows. The value of contrast LV opacification (LVO) for WMSI assessment is not well known. Objectives: We sought to compare interobserver agreement for WMSI and the correlation between the LVO-WMSI and LV-EF using two-dimensional second harmonic (SH) and LVO echocardiography. Methods: The study comprised 100 consecutive patients (57 ± 13 years, 85% males). Two independent physicians assessed LV segmental quality and wall motion for both the SH and LVO studies according to a 17-segment model. Systolic wall motion was defined as: normokinesia, hypokinesia (systolic inward endocardial motion <7 mm), akinesia, and dyskinesia. LV-EF was assessed from the LVO images according to the biplane modified Simpson's method. Results: Of the 1,700 analyzed segments, 453 (26.6%) were poorly visualized with SH imaging, and 173 (10.2%) with LVO (P < 0.0001). The two observers agreed on segmental wall motion score in 1,299 segments (agreement 76%, Kappa 0.60) with SH imaging and in 1,491 segments (agreement 88%, Kappa 0.78) with LVO. Interobserver correlation (r2) was 0.86 for the SH-WMSI and 0.93 for the LVO-WMSI. The limits-of-agreement for interobserver LVO-WMSI (mean difference -1.0%± 6.8%, agreement -14.6%, 12.6%) was lower than that for SH-WMSI (mean difference -2.3%± 10.1%, agreement -22.5, 17.9). The LVO-WMSI correlated well with LV-EF (r2= 0.71). LV-EF could be estimated according to the formula 1.01 - 0.32 × WMSI. Conclusion: Echo-contrast improves interobserver agreement for wall motion scoring and the WMSI. The LVO-imaged WMSI correlates well with LV-EF.

Distribution of echocardiographic parameters and their associations with cardiovascular risk factors in the Rotterdam Study (Article)

2010-07-01T00:00:00Z

Insight into echocardiographic parameters in the general population may facilitate early recognition of ventricular dysfunction, reducing the population morbidity and mortality of heart failure. We examined the distribution of structural, systolic and diastolic echocardiographic parameters and their associations with cardiovascular risk factors in the Rotterdam Study, a population-based cohort study in men and women aged ≥55 years. Participants with prevalent heart failure, myocardial infarction and atrial fibrillation and flutter were excluded. Echocardiographic parameters were assessed using two-dimensional, M-mode and Doppler echocardiography. Echocardiograms were available in 4,425 participants. Structural parameters were generally larger in men, and most consistently associated with age, body mass index and blood pressure in both sexes. Prevalence of moderate or poor left ventricular systolic function was 3.9% in men and 2.1% in women. Age, body mass index and blood pressure were most consistently associated with systolic function. E/A ratio was lower in women than in men. Age and diastolic blood pressure were most consistently associated with E/A ratio in both sexes. In conclusion, ventricular systolic and diastolic dysfunction is present in asymptomatic individuals. Selected established cardiovascular risk factors are associated with structural, systolic and diastolic parameters.

Left ventricular untwisting in restrictive and pseudorestrictive left ventricular filling: Novel insights into diastology (Article)

2010-03-01T00:00:00Z

Background: Conceptually, an ideal therapeutic agent should target the underlying mechanisms that cause left ventricular (LV) diastolic dysfunction. The objective of our study was to gain further insight into the mechanics of diastology by comparison of LV untwisting measured by speckle tracking echocardiography (STE) in young healthy adults with normal and "pseudorestrictive" LV filling, and dilated cardiomyopathy (DCM) patients with "true restrictive" LV filling. Methods: The study comprised 20 healthy volunteers with a Doppler LV-inflow pattern compatible with restrictive LV filling but a diastolic early phase filling velocity/early diastolic velocity of the mitral annulus (E/Em) ratio <8 (" pseudorestrictive"), 20 for age and gender-matched healthy volunteers with normal LV filling and an E/Em ratio <8, and 10 DCM patients with "true restrictive" LV filling and an E/Em ratio >15. LV untwisting parameters were determined by STE. Results: Compared to healthy subjects, DCM patients had decreased peak diastolic untwisting velocity (-62 ± 33 degrees/s vs -113 ± 25 degrees/s, P < 0.01) and untwisting rate (-15 ± 9 degrees/s vs -51 ± 24 degrees/s, P < 0.01). Compared to healthy subjects with normal LV filling, healthy subjects with " pseudorestrictive" LV filling had increased peak diastolic untwisting velocity (-123 ± 25 degrees/s vs -104 ± 30 degrees/s, P < 0.05) and untwisting rate (-59 ± 23 degrees/s vs -44 ± 22 degrees/s, P < 0.05). Conclusion: Faster LV untwisting plays a pivotal role in the rapid early diastolic filling occasionally seen in young healthy individuals. In contrast, in DCM patients untwisting is severely delayed and this impairment to utilize suction may reduce LV filling.

Thrombus in a normal left ventricle: A cardiac manifestation of pheochromocytoma (Article)

2010-02-01T00:00:00Z

In this case report, a patient with a thrombus in a normal-sized and functional left ventricular is described. The thrombus was most likely formed during pheochromocytoma crisis with severe transient wall motion abnormalities.

Prediction of Appropriate Defibrillator Therapy in Heart Failure Patients Treated With Cardiac Resynchronization Therapy (Article)

2010-01-01T00:00:00Z

The necessity of implantable cardioverter-defibrillator (ICD) implantation in patients with systolic heart failure (HF) who undergo cardiac resynchronization therapy (CRT) may be questioned. The aim of this study was to identify patients at low risk for sustained ventricular arrhythmia. One hundred sixty-nine consecutive patients with HF (mean age 60 ± 12 years, 125 men, 73% in New York Heart Association class III) referred for CRT and prophylactic, primary prevention ICD implantation underwent baseline clinical and echocardiographic assessment and regular device follow-up. The primary study end point was appropriate ICD therapy. During a mean follow-up period of 654 ± 394 days, 35 patients (21%) had sustained ventricular arrhythmias requiring appropriate ICD therapy. Of the 3 patients who experienced sudden cardiac death, 2 had been treated with appropriate ICD therapy before sudden cardiac death. In a multivariate model, only history of nonsustained ventricular tachycardia (p = 0.001), a severely (<20%) decreased left ventricular ejection fraction (p = 0.001), and digitalis therapy (p = 0.08) independently predicted appropriate ICD therapy. Patients with 0 (n = 46), 1 (n = 36), 2 (n = 73), and 3 (n = 14) risk factors for appropriate ICD therapy had a 7%, 14%, 27%, and 64% and 0%, 6%, 10%, and 43% incidence of appropriate ICD therapy for ventricular arrhythmias and for rapid ventricular tachycardia or ventricular fibrillation, respectively. In conclusion, apart from commonsense considerations (age and significant co-morbidities), ICD addition seems ineffective in CRT patients without nonsustained ventricular tachycardia, digoxin therapy, and severely reduced left ventricular systolic function.

Influence of cardiac shape on left ventricular twist (Article)

2010-01-01T00:00:00Z

The dynamic interaction between subendocardial and subepicardial fibre helices in the left ventricle (LV) leads to a twisting deformation, which has an important role in LV function. This study sought to assess the influence of cardiac shape on LV twist in the normal and dilated human heart. The study comprised 45 dilated cardiomyopathy (DCM) patients and 60 for age- and gender-matched healthy volunteers. Speckle tracking echocardiography was used to determine basal and apical LV peak systolic rotation (Rotmax) and instantaneous LV peak systolic twist (Twistmax). LV sphericity index was calculated by dividing the LV maximal long-axis internal dimension by the maximal short-axis internal dimension at end-diastole. A parabolic relation between the sphericity index and apical Rotmaxor Twistmaxwas identified in the total study population (R2= 0.56 and R2= 0.54, respectively; both P < 0.001) and healthy volunteers (R2= 0.39 and R2= 0.25, respectively; both P < 0.001), whereas these relations were linear in DCM patients (R2= 0.40 and R2= 0.43, respectively; both P < 0.001). In a multivariate analysis, LV sphericity index was the strongest independent predictor of apical Rotmaxand Twistmax. In conclusion, LV apical rotation and twist are significantly influenced by LV configuration. Taking the important function of LV twist into account, this finding highlights the vital influence of cardiac shape on LV systolic function. Copyright

Alterations in left ventricular untwisting with ageing (Article)

2010-01-01T00:00:00Z

Background: In order to gain further insight into age-associated changes of left ventricular (LV) diastolic function, the purpose of the current study was to investigate alterations in LV untwisting with ageing. Methods and Results: The study comprised 75 healthy volunteers, classified into 3 groups: age 16-35 (n=25), 36-55 (n=25) and 56-75 (n=25) years. LV untwisting (as a percentage of peak systolic twist) at 5%, 10%, 15% and 50% of diastole, peak diastolic untwisting velocity, time-to-peak diastolic untwisting velocity and untwisting rate (mean untwisting velocity during the time interval from peak systolic twist to mitral valve opening) were assessed using speckle-tracking echocardiography. Untwisting at 5%, 10%, 15% and 50% of diastole decreased with ageing. Although the peak diastolic untwisting velocity and untwisting rate were not significantly different between the age groups, when normalized for LV peak systolic twist, these parameters decreased with advancing age (both P<0.01). Time-to-peak diastolic untwisting velocity increased with ageing (P<0.01). Conclusions: Impairment of the relative peak diastolic untwisting velocity and untwisting rate, resulting in delayed LV untwisting, may help to explain diastolic dysfunction in the elderly.

Delayed Left Ventricular Untwisting in Hypertrophic Cardiomyopathy (Article)

2009-12-01T00:00:00Z

Background: Almost all patients with hypertrophic cardiomyopathy (HCM) have some degree of left ventricular (LV) diastolic dysfunction. Nevertheless, the pathophysiology remains incompletely characterized. Conceptually, an ideal therapeutic agent should target the underlying mechanisms that cause LV diastolic dysfunction. Assessment of diastolic LV untwisting could potentially be helpful to gain insight into the mechanism of diastolic dysfunction. The purpose of this study was to investigate LV untwisting in patients with HCM and control subjects. Methods: LV untwisting parameters were assessed using speckle-tracking echocardiography in 75 consecutive patients with HCM and compared with those from 75 healthy control subjects. Results: Untwisting at 5%, 10%, and 15% of diastole was lower in patients with HCM (all P values < .001) compared with control subjects. Peak diastolic untwisting velocity (-92 ± 32°/s vs -104 ± 39°/s, P < .05) and untwisting rate from peak systolic twist to mitral valve opening (MVO) (-37 ± 20°/s vs -46 ± 22°/s, P < .01) were lower, while the for diastolic duration normalized time-to-peak diastolic untwisting velocity (17 ± 9% vs 13 ± 9%, P < .05) was higher in patients with HCM. Untwisting rate from peak systolic twist to MVO was negatively correlated with the E/A ratio (R2 = 0.15, P < .01). Peak diastolic untwisting velocity and untwisting rate from peak systolic twist to MVO were increased in mild but decreased in moderate and severe diastolic dysfunction compared with control subjects. Conclusion: LV untwisting is delayed in HCM, which probably significantly contributes to diastolic dysfunction.

Assessment of Mitral Annular Velocities by Speckle Tracking Echocardiography versus Tissue Doppler Imaging: Validation, Feasibility, and Reproducibility (Article)

2009-11-01T00:00:00Z

Background: Mitral annular velocity may be measured angle independently by speckle tracking echocardiography (STE), in contrast with tissue Doppler imaging (TDI). The purpose of the current study was to compare STE and TDI, with respect to 1) the accuracy of velocity measurements in a moving phantom, 2) the feasibility and reproducibility of measurement of mitral annular velocities in a clinical setting, and 3) the estimation of left ventricular filling pressures using mitral annular velocities. Methods: The velocity of a moving phantom, using different angles of insonation, and mitral annular velocities of 80 nonselected patients and 50 healthy volunteers were determined using TDI and STE. A subgroup of 20 patients was studied during right-sided heart catheterization. Results: When the motion direction of the phantom was parallel to the ultrasound beam, both TDI and STE determined velocities accurately. With increasing angle of insonation, TDI-derived velocity decreased, whereas STE-derived velocity remained unchanged. The feasibility of mitral annular velocities measured by TDI and STE was comparable (98% vs 95%, P = not significant). Although for both techniques correlations between measured mitral annular velocities at repeated examinations were good, the test-retest variability of mitral annular velocities by TDI was higher. E/Em ratio by STE correlated better to pulmonary capillary wedge pressure (R2= 0.51, P < .001) compared with E/Em ratio derived from TDI (R2= 0.35, P < .01), although the difference in correlation was not statistically significant because of the limited sample size. Conclusion: Tissue velocities can be accurately determined by STE in a moving phantom and are angle independent, in contrast with TDI measurements. Furthermore, STE is a feasible and better reproducible method for the assessment of mitral annular velocities in a clinical setting.

Feasibility and reproducibility of left ventricular rotation parameters measured by speckle tracking echocardiography (Article)

2009-07-01T00:00:00Z

AimsThis study sought to find the most robust method for left ventricular (LV) rotation measurement by speckle tracking echocardiography (STE) with the new QLAB Advanced Quantification Software (version 6.0, Philips, Best, The Netherlands).Methods and resultsThe study population consisted of 40 non-selected patients (mean age 48 ± 18 year, 20 men) and 50 non-selected healthy volunteers (mean age 34 ± 12 year, 21 men). Feasibility and intra-observer reproducibility of the measurement of LV rotation parameters by STE were assessed for two different methods (Method A: six tracking points placed mid-myocardial and Method B: six tracking points placed endocardial and epicardial forming six myocardial segments). Subsequently, inter-observer and temporal reproducibility of the most robust method were assessed. Complete LV rotation assessment was more feasible with Method A (60 out of 90 subjects, 67 vs. 50 out of 90 subjects, 56). In the 49 subjects in whom both Methods A and B were feasible, intra-observer reproducibility of LV rotation parameters was better with Method A (variabilities 2 ± 3 to 10 ± 9 vs. 2 ± 4 to 21 ± 18). With this method, inter-observer variability varied from 4 ± 4 to 13 ± 9 and temporal variability from 4 ± 6 to 19 ± 15.ConclusionThe most robust method to assess LV rotation with QLAB software is from the mid-myocardium. This method is feasible in approximately two-thirds of subjects and has good intra-observer, inter-observer, and temporal reproducibility, allowing to study changes over time in LV rotation in an individual patient.

Usefulness of Left Ventricular Systolic Dyssynchrony by Real-Time Three-Dimensional Echocardiography to Predict Long-Term Response to Cardiac Resynchronization Therapy (Article)

2009-06-01T00:00:00Z

Real-time 3-dimensional echocardiography (RT3DE) allows simultaneous timing of regional volumetric changes as a net result of longitudinal, radial, circumferential left ventricular (LV) contraction, hence LV systolic dyssynchrony. We sought to examine real-time 3-dimensional echocardiographically derived dyssynchrony for prediction of long-term response to cardiac resynchronization therapy (CRT) in a prospective study. Ninety consecutive patients with heart failure (mean age 60 ± 12 years, 73% men, New York Heart Association class III in 97%) underwent clinical and echocardiographic assessments at baseline and at 12 months after CRT including real-time 3-dimensional echocardiographically derived LV systolic dyssynchrony index. The systolic dyssynchrony index (SDI) was defined as the SD of time to minimum systolic volume of the 16 LV segments, expressed in percent RR duration. CRT response was defined as a >15% decrease in LV end-systolic volume on real-time 3-dimensional echocardiogram. After 12 months of CRT, 68 patients (76%) were responders. Feasibility of the SDI was 94%. An SDI >10% predicted CRT response with good sensitivity (96%), specificity (88%), positive likelihood ratio (8), and negative likelihood ratio (0.05). Patients with an SDI >10% had mean change (-21%, -31%, 39% vs -13%, -10%, 10%) in LV end-diastolic volume, LV end-systolic volume, and LV ejection fraction, respectively, compared with baseline versus patients with an SDI <10% (p <0.01). Mean acquisition and analysis duration of single-patient RT3DE was 8 minutes (range 6 to 13). Interobserver variabilities of LV end-systolic volume and SDI were 5% and 11%, respectively. In conclusion, RT3DE provides accurate identification of reverse volumetric LV remodeling after CRT. From these accurate volumetric data, RT3DE provides more intuitive assessment of dyssynchrony and response to CRT as a simple, reproducible, and fast technique. CRT can be individually tailored using RT3DE and seems very effective in patients with heat failure with real-time 3-dimensional echocardiographic evidence of dyssynchrony.

Reduced regional systolic function is not confined to the noncompacted segments in noncompaction cardiomyopathy (Article)

2009-05-29T00:00:00Z

Background: Isolated ventricular noncompaction (IVNC) is a relatively rare genetic primary cardiomyopathy. The aim of the present study was to investigate with regional real-time three-dimensional echocardiographic analysis whether there is a difference between the contribution of noncompacted and compacted left ventricular (LV) segments to global LV dysfunction in patients with IVNC. Methods: The study comprised 289 segments of 17 patients with stringent diagnostic criteria for IVNC. Their results were compared to 153 segments of 9 control subjects. The systolic performance of compacted and noncompacted LV segments was assessed using the wall motion score during 2D echocardiography. The 3D images were acquired with a RT3DE system with X4 matrix-array transducer and were used for the regional volume measurements. Results: Wall motion score index was markedly abnormal in the compacted LV segments of IVNC patients but significantly less abnormal compared to the noncompacted segments (2.21 ± 0.63 vs. 2.01 ± 0.74, p < 0.05). No relationship was found between the number of noncompacted segments per patient and LV ejection fraction or end-diastolic volume. In the IVNC patients, noncompacted and compacted LV segments had comparable increased 3D regional volumes and reduced systolic function. Conclusions: These results suggest that systolic LV dysfunction observed in IVNC is not confined to noncompacted LV segments.

Echocardiographic parameters and all-cause mortality: The Rotterdam Study (Article)

2009-04-03T00:00:00Z

Background: Even when heart failure has not yet become clinically manifest, preclinical ventricular dysfunction may be present, and therapeutic interventions introduced at this time may reduce morbidity and mortality. However, data on the predictive value of echocardiographic characteristics in the general population remain relatively scarce. Methods: The Rotterdam Study is a population-based cohort study in men and women aged ≥ 55 years. Participants with prevalent heart failure, myocardial infarction and atrial fibrillation and flutter at the time of echocardiography were excluded. Structural, systolic and diastolic parameters were assessed using two-dimensional, M-mode and Doppler echocardiography. Echocardiograms were available in 4425 participants. Results: During a mean follow-up of 3.0 years, 226 participants died. Increased left ventricular mass was an independent risk factor for all-cause mortality, particularly in men (hazard ratio per standard deviation of natural log transformed left ventricular mass, 1.20 (95% CI, 1.01-1.43)). Fractional shortening and left ventricular systolic function did not show a clear association with mortality. E/A ratio < 0.75 was an independent risk factor in men (age-adjusted hazard ratio 1.82 (95% CI 1.23-2.69)). This was further reflected by diastolic function: impaired relaxation was a risk factor in men, but not in women. Conclusions: Structural and diastolic echocardiographic parameters are associated with all-cause mortality in an asymptomatic population. However, the evidence is still inadequate to support the usefulness of echocardiography for screening to identify asymptomatic individuals with preclinical ventricular dysfunction.

Influence of the pattern of hypertrophy on left ventricular twist in hypertrophic cardiomyopathy (Article)

2009-04-01T00:00:00Z

Background/objective: Left ventricular (LV) twist has an important role in LV function. The influence of the pattern of LV hypertrophy on LV twist in hypertrophic cardiomyopathy (HCM) patients is unknown. This study sought to assess LV twist in a large group of HCM patients according to the pattern of LV hypertrophy. Methods: The final study population consisted of 43 patients with HCM (mean age 43 (15) years, 31 men) and a typical sigmoidal (n = 16) or reverse septal curvature (n = 27) and 43 age-matched and gender-matched healthy control subjects. LV peak systolic rotation (Rotmax), LV peak systolic twist (Twistmax) and untwisting at 5%, 10% and 15% of diastole were determined by speckle tracking echocardiography (STE). Results: Compared to control subjects, HCM patients had increased basal Rotmax (-5.5° (2.3°) vs -3.4° (1.7°), p<0.001) and comparable apical Rot max (7.3° (3.1°) vs 7.0° (2.2°), p = NS), resulting in increased Twistmax (12.4° (4.0°) vs 9.9° (2.7°), p<0.01). Untwisting at 5%, 10% and 15% of diastole was decreased in HCM patients (all p<0.05). There was a striking difference in apical Rot max (9.4° (2.8°) vs 6.0° (2.6°), p<0.01) and Twistmax (15.3° (3.2°) vs 10.6° (3.3°), p<0.01) between HCM patients with a sigmoidal and reverse septal curvature. Conclusions: STE may provide novel non-invasive indices to assess LV function in patients with HCM. Apical Rotmax and Twistmax in HCM patients are dependent on the pattern of LV hypertrophy.

Insights into left ventricular function from the time course of regional and global rotation by speckle tracking echocardiography (Article)

2009-04-01T00:00:00Z

Background: Description and quantification of regional left ventricular (LV) rotation and the time course of LV rotation might provide further insight into LV function. Methods: The study comprised 60 healthy volunteers (age 39 ± 15 years, 31 men) in whom complete global and regional LV rotation could be assessed at both the basal and apical LV level with speckle tracking echocardiography, using QLAB advanced quantification software version 6.0 (Philips, Best, The Netherlands). Results: At the LV basal level, a brief counterclockwise rotation from aortic valve opening until 25% ejection was seen in the anterior segments (anterior, anteroseptal, anterolateral) only. Clockwise rotation in the anterior segments at the basal level was decreased as compared to the posterior segments (inferior, inferoseptal, inferolateral) from 25% ejection until aortic valve closure. At the LV apical level, all segments showed a brief clockwise rotation during the isovolumic contraction phase. Also, at this level there were no differences in regional LV rotation at any other moment during the cardiac cycle. There was a marked de-rotation from the moment of maximal rotation until E-peak at the LV basal level (79 ± 18%) whereas de-rotation during this interval was less pronounced at the LV apical level (55 ± 21%). Only at the LV basal level significant linear relationships were seen between the E/A ratio and de-rotation extent and velocity from mitral valve opening until E-peak (R2 = 0.42 and R2 = 0.40, respectively, both P < 0.001). Conclusion: In the normal human heart significant regional differences in LV rotation and de-rotation exist.

Quantification of Left Ventricular Systolic Dyssynchrony by Real-Time Three-Dimensional Echocardiography (Article)

2009-03-01T00:00:00Z

Objective: To assess real-time 3-dimensional echocardiography (RT3DE)-derived left ventricular (LV) systolic dyssynchrony parameters: (1) normal values, (2) characteristics in patients with heart failure (HF) and a wide or narrow QRS complex, (3) interobserver and intraobserver variability with current state of the art RT3DE hardware and software technology, and (4) incremental value in patients with HF who receive cardiac resynchronization therapy (CRT). Methods: The study involved 84 patients with HF (mean age 54 ± 15 years, 50 men) and 60 healthy volunteers (mean age 41 ± 15 years, 36 men). Semiautomated LV endocardial border tracking was used to calculate regional time-to-minimum systolic volume and to generate parametric maps and the systolic dyssynchrony index (SDI), defined as the standard deviation of time-to-minimum systolic volume of the 16 LV segments expressed in percentage of R-R duration. Results: The volume rate of the RT3DE datasets in patients with HF was 31 ± 9 Hz (range 15-42 Hz). The normal value of the SDI was 4.1% ± 2.2% (range <1.0%-8.9%). Patients with HF had a larger SDI (13.4% ± 8.1%, P < .001). There was only a weak correlation (r2 = 0.07, P < .05) between the QRS duration and the SDI. Interobserver interclass correlation and variability of the SDI depended on image quality (good: 0.993 and 9%, moderate: 0.907 and 16%, respectively). Interobserver agreement for the identification of the most delayed LV segment depended on image quality (good: 90%, moderate: 76%). Thirty-nine patients underwent CRT. At the 12-month follow-up, LV volumetric responders had a significant reduction in the SDI (16.3% ± 3.3% to 7.7% ± 2.4%, P < .001). Conclusion: With state of the art technology, RT3DE allows reproducible assessment of LV systolic dyssynchrony, which may be useful to identify potential responders to CRT.

Side-by-side viewing of anatomically aligned left ventricular segments in three-dimensional stress echocardiography (Article)

2009-02-01T00:00:00Z

Background: Dobutamine stress echocardiography (DSE) suffers from high interobserver and inter-institution variability in the diagnosis of myocardial ischemia. Therefore, we developed a three-dimensional (3D) analysis tool that makes it possible to anatomically align 3D rest and stress data systematically, to generate optimal, nonforeshortened standard anatomical cross sections and to analyse the images synchronized and side-by-side. Aim of the study: To investigate whether this 3D analysis tool could improve interobserver agreement on myocardial ischemia during 3D DSE. Methods: The study comprised 34 consecutive patients with stable chest pain who underwent both noncontrast and contrast 3D DSE. Two observers scored segmental wall motion using a conventional analysis and the novel analysis with the new 3D tool. Results: The two observers agreed on the presence or absence of myocardial ischemia in 81 of 102 coronary territories (agreement 79%, kappa (κ) 0.28) during noncontrast 3D imaging and 92 of 102 coronary territories (agreement 90%, kappa 0.65) during contrast-enhanced 3D imaging. With the new 3D analysis software these numbers improved to 98 of 102 coronary territories (agreement 96%, kappa 0.69) during noncontrast 3D imaging and 98 of 102 coronary territories (agreement 96%, kappa 0.82) during contrast-enhanced 3D imaging. Conclusion: The use of a 3D DSE analysis tool improves interobserver agreement for myocardial ischemia both for noncontrast and contrast images.

Adverse reactions after the use of sulphur hexafluoride (SonoVue) echo contrast agent (Article)

2009-01-01T00:00:00Z

The aim of the present study was to analyse the adverse effects of SonoVue echo contrast in a consecutive series of 352 cardiac patients during a 4-year period. During 352 consecutive cardiac SonoVue studies, seven patients (2.0%) experienced adverse effects. Four patients (1.1%) had mild allergic reactions causing skin erythema and mild sinus tachycardia, and three patients (0.9%) experienced a severe allergic reaction resulting in (nonfatal) shock. The reported incidence of adverse effects of SonoVue echo contrast in this consecutive series of cardiac patients seems markedly higher than those reported in a company postmarketing analysis.

Cardiac evaluation in children and adults with Pompe disease sharing the common c.-32-13T>G genotype rarely reveals abnormalities (Article)

2008-12-15T00:00:00Z

Background and objective: Pompe disease is an inherited metabolic disorder caused by deficiency of acid α-glucosidase. All affected neonates have a severe hypertrophic cardiomyopathy, leading to cardiac failure and death within the first year of life. We investigated the presence and extent of cardiac involvement in children and adults with Pompe disease with the common c.-32-13T>G genotype to determine the usefulness of cardiac screening in these patients with relatively 'milder' phenotypes. Methods: Cardiac dimensions and function were evaluated through echocardiography, electrocardiography and Holter monitoring. The total group comprised 68 patients with Pompe disease, of whom 22 patients had disease onset before the age of 18. Results: Two patients (3%) had cardiac abnormalities possibly related to Pompe disease: Electrocardiography showed a Wolff-Parkinson-White pattern in an 8-year-old girl, and one severely affected adult patient had a mild hypertrophic cardiomyopathy. This hypertrophy did not change during treatment with recombinant human α-glucosidase. In addition, four adult patients showed minor cardiac abnormalities which did not exceed the prevalence in the general population and were attributed to advanced age, hypertension or pre-existing cardiac pathology unrelated to Pompe disease. Conclusions: Cardiac involvement is rare in Pompe patients with the common c.-32-13T>G genotype. The younger patients were not more frequently affected than the adults. Electrocardiographic evaluation appears to be appropriate as initial screening tool. Extensive cardiac screening seems indicated only if the electrocardiogram is abnormal or the patient has a history of cardiac disease.

Left ventricular solid body rotation in non-compaction cardiomyopathy: A potential new objective and quantitative functional diagnostic criterion? (Article)

2008-11-01T00:00:00Z

Background: Left ventricular (LV) twist originates from the interaction between myocardial fibre helices that are formed during the formation of compact myocardium in the final stages of the development of myocardial architecture. Since non-compaction cardiomyopathy (NCCM) is probably caused by intrauterine arrest of this final stage, it may be anticipated that LV twist characteristics are altered in NCCM patients, beyond that seen in patients with impaired LV function and normal compaction. Aims: The purpose of this study was to assess LV twist characteristics in NCCM patients compared to patients with non-ischaemic dilated cardiomyopathy (DCM) and normal subjects. Methods and results: The study population consisted of 10 patients with NCCM, 10 patients with DCM, and 10 healthy controls. LV twist was determined by speckle tracking echocardiography. In all controls and DCM patients, rotation was clockwise at the basal level and counterclockwise at the apical level. In contrast, in all NCCM patients the LV base and apex rotated in the same direction. Conclusions: These findings suggest that 'LV solid body rotation', with near absent LV twist, may be a new sensitive and specific, objective and quantitative, functional diagnostic criterion for NCCM.

Contrast-enhanced three-dimensional dobutamine stress echocardiography: Between Scylla and Charybdis? (Article)

2008-11-01T00:00:00Z

Aims: Real-time three-dimensional echocardiography (RT3DE) allows quick volumetric scanning of the left ventricle (LV). We evaluated the diagnostic accuracy of contrast-enhanced stress RT3DE for the detection of coronary artery disease (CAD) in comparison with coronary arteriography as the reference technique. Methods and results: Forty-five consecutive patients (age 59 ± 10, 31 males) referred for coronary angiography were examined by contrast-enhanced RT3DE. Wall motion analysis was performed off-line by dedicated software. New or worsening wall motion abnormalities were detected in 17 of 28 patients with significant CAD (sensitivity 61%), and in two of 17 patients without significant CAD (specificity 88%). The sensitivity for detection of single-vessel CAD was 8/15 patients (53%), for two-vessel CAD 4/6 (67%), and for three-vessel CAD 5/7 (71%). In 35 patients, comparison with conventional RT3DE was available. The image quality index at rest improved from 2.5 ± 1.2 to 3.2 ± 1.0 (P < 0.001) with contrast and at peak stress from 2.3 ± 1.2 to 3.1 ± 1.0 (P < 0.001). Interobserver agreement on the diagnosis of myocardial ischaemia improved from 26 of 35 studies (74%, κ = 0.44) with conventional stress RT3DE to 30 of 35 studies (86%, κ = 0.69) with contrast-enhanced stress RT3DE. Sensitivity increased from 50 to 55% and specificity from 69 to 85% with contrast-enhanced stress RT3DE in this subset of patients. Conclusion: Despite some important practical and theoretical benefits, contrast-enhanced stress RT3DE currently has only moderate diagnostic sensitivity due to several technical limitations as temporal and spatial resolution.

Cardiac involvement in adults with Pompe disease (Article)

2008-10-01T00:00:00Z

Background. Glycogen storage disease type II or Pompe disease is a neuromuscular disorder caused by deficiency of lysosomal acid α- glucosidase. Classic infantile Pompe disease results in massive left ventricular (LV) hypertrophy and failure. Although Pompe disease is often included in the differential diagnosis of LV hypertrophy the true frequency of cardiac involvement in adults with Pompe disease is not known. Methods. Forty-six consecutive adult patients (mean age 48 ± 12, 22 men) with Pompe disease were included. Each patient underwent a clinical examination, electrocardiography, and rest and low-dose dobutamine (in 20 patients) two-dimensional echocardiography including contrast and tissue Doppler imaging. Results. All patients had limited exercise tolerance; a rollator walking aid was used in seven patients (15%), a wheelchair in 13 patients (28%), and assisted ventilation in 14 patients (30%). Prior to this study, one patient was known with permanent atrial fibrillation, His-bundle ablation and a VVI pacemaker and another patient was known with fluid retention. The first patient had increased LV end-diastolic diameter, impaired LV ejection fraction, low systolic mitral annular velocities and diastolic dysfunction grade II. The patient with fluid retention was wheelchair bound and dependent on 24-h assisted ventilation and showed right ventricular and LV hypertrophy (septum 16 mm, posterior wall 15 mm). LV hypertrophy was not seen in any of the other patients. One woman of advanced age had isolated low systolic mitral annular velocities. Mean global systolic LV function, including contractile reserve, was not decreased in patients with Pompe disease. Eight patients (17%) had mild diastolic dysfunction grade I, related to hypertension in four and advanced age in seven. Conclusions. In adult patients with Pompe disease without objective signs of cardiac affection by 12-leads electrocardiography or physical examination, echocardiographic screening for LV hypertrophy seems not effective.

Age-related changes in the biomechanics of left ventricular twist measured by speckle tracking echocardiography (Article)

2008-10-01T00:00:00Z

The increasing number and proportion of aged individuals in the population warrants knowledge of normal physiological changes of left ventricular (LV) biomechanics with advancing age. LV twist describes the instantaneous circumferential motion of the apex with respect to the base of the heart and has an important role in LV ejection and filling. This study sought to investigate the biomechanics behind age-related changes in LV twist by determining a broad spectrum of LV rotation parameters in different age groups, using speckle tracking echocardiography (STE). The final study population consisted of 61 healthy volunteers (16-35 yr, n = 25; 36-55 yr, n = 23; 56-75 yr, n = 13; 31 men). LV peak systolic rotation during the isovolumic contraction phase (Rotearly), LV peak systolic rotation during ejection (Rotmax), instantaneous LV peak systolic twist (Twistmax), the time to Rotearly, Rotmax, and Twistmax, and rotational deformation delay (defined as the difference of time to basal Rotmaxand apical Rotmax) were determined by STE using QLAB Advanced Quantification Software (version 6.0; Philips, Best, The Netherlands). With increasing age, apical Rotmax(P < 0.05), time to apical Rotmax(P < 0.01), and Twistmax(P < 0.01) increased, whereas basal Rotearly(P < 0.001), time to basal Rotearly(P < 0.01), and rotational deformation delay (P < 0.05) decreased. Rotational deformation delay was significantly correlated to Twistmax(R2= 0.20, P < 0.05). In conclusion, Twistmaxincreased with aging, resulting from both increased apical Rotmaxand decreased rotational deformation delay between the apex and the base of the LV. This may explain the preservation of LV ejection fraction in the elderly. Copyright

Accuracy and Reproducibility of Quantitation of Left Ventricular Function by Real-Time Three-Dimensional Echocardiography Versus Cardiac Magnetic Resonance (Article)

2008-09-15T00:00:00Z

The aim of this study was to investigate the accuracy and reproducibility of the quantification of left ventricular (LV) function by real-time 3-dimensional echocardiography (RT3DE) using current state-of-the-art hardware and software. Compared with cardiac magnetic resonance (CMR), previous generations of hardware and software for RT3DE significantly underestimated LV volumes partly because of inherent factors such as limited spatial and temporal resolution. Also, RT3DE volumes were compared with short-axis CMR data, whereas a combined short-axis and long-axis analysis is known to be superior. Twenty-four subjects (mean age 51 ± 12 years, 17 men) in sinus rhythm and with good to excellent 2-dimensional image quality underwent RT3DE and CMR within 1 day. The acquisition of RT3DE data was done with current state-of-the-art hardware and software. Two blinded experts performed off-line LV volume analysis. Global LV volumes were determined from semiautomated border detection on the basis of endocardial speckle tracking with biplane projections using QLAB version 6.0. Volumes derived by magnetic resonance imaging were quantified from combined short-axis and long-axis series. The volume-rate on RT3DE was 33 ± 8 Hz (range 19 to 42). Excellent correlations were found (R2≥ 0.97) between CMR and RT3DE for global LV end-diastolic volume, LV end-systolic volume, the LV ejection fraction, and LV phase volumes (24 phases/cardiac cycle). Bland-Altman analyses showed mean differences of -7.1 ml, -4.2 ml, 0.2%, and -5.8 ml and 95% limits of agreement of ±19.7 ml, ±8.3 ml, ±6.2%, and ±15.4 ml for global LV end-diastolic volume, LV end-systolic volume, the LV ejection fraction, and LV phase volumes, respectively. Interobserver variability was 5.2% for global LV end-diastolic volume, 6.4% for LV end-systolic volume, and 7.6% for the LV ejection fraction. In conclusion, in patients with good acoustic windows, RT3DE using state-of-the-art technology provides accurate and reproducible measurements of global LV volumes, LV volume changes over time, and the LV ejection fraction.

Associations between plasma natriuretic peptides and echocardiographic abnormalities in geriatric outpatients (Article)

2008-09-01T00:00:00Z

Identification of patients with cardiac dysfunction can be difficult in the geriatric population. Recently, different subtypes of the natriuretic peptide family have been advocated as biomarker for the diagnosis of heart failure in the emergency department setting. In this study we looked at associations between natriuretic peptide plasma levels and echocardiographic abnormalities in geriatric outpatients. Two-dimensional transthoracic echocardiography was performed in 209 community-dwelling subjects, visiting the geriatric outpatient clinic of our university hospital. Subjects were 65 years or older and had no markedly impaired cognitive function. Mean atrial natriuretic peptide (ANP) and B-type natriuretic peptide (BNP) plasma levels were respectively 11.0 and 10.8 pmol/l. BNP, but not ANP correlated with left ventricular dysfunction and left ventricular mass, whereas both peptides correlated with left atrial dimension and valvular lesions. A natriuretic peptide level in the highest tertile was associated with a higher risk of any echocardiographic abnormality, with odds ratios for BNP of 7.15 (range 2.15-23.71), and for ANP of 3.07 (range 1.15-8.16). In conclusion, elevated BNP and ANP plasma levels are closely related to cardiac abnormalities in elderly subjects. The association between cardiac abnormalities and natriuretic peptides is stronger for BNP than for ANP, hence for detection of cardiac abnormalities measurement of BNP plasma values are preferred over ANP plasma values.

Importance of Transducer Position in the Assessment of Apical Rotation by Speckle Tracking Echocardiography (Article)

2008-08-01T00:00:00Z

Background: Speckle tracking echocardiography is increasingly used to quantify left ventricular (LV) twist. However, one of the limitations of the assessment of LV twist by speckle tracking echocardiography is the crucial dependence on correct acquisition of a LV apical short-axis. This study sought to assess the influence of transducer position on LV apical rotation measurements. Methods: The study population consisted of 58 consecutive healthy volunteers (mean age 38 ± 13 years, 25 men). To obtain parasternal short-axis images at the LV apical level, the following protocol was used. From the standard parasternal position (LV and aorta most inline, with the mitral valve tips in the middle of the sector) an as-circular-as-possible short-axis image of the LV apex, just proximal to the level with end-systolic LV luminal obliteration, was obtained by angulation of the transducer (position 1). From this position, the position of the transducer was changed to one (position 2) and two (position 3) intercostal spaces more caudal with subsequent similar transducer adaptations. Results: In 8 volunteers (14%) parasternal image quality was insufficient for speckle tracking echocardiography. In 13 volunteers (22%) the LV apical short-axis could only be obtained from one transducer position. In the remaining volunteers with two (n = 27) or three (n = 10) available transducer positions, a more caudal transducer position was associated with increased measured LV apical rotation. Mean measured LV apical rotation was 5.2 ± 1.8 degrees at position 1, 7.3 ± 2.6 degrees at position 2 (P < .001), and 8.7 ± 2.2 degrees at position 3 (P < .001 vs position 1 and P < .05 vs position 2). Conclusion: A more caudal transducer position is associated with increased measured LV apical rotation.

Four-year follow-up of treatment with intramyocardial skeletal myoblasts injection in patients with ischaemic cardiomyopathy (Article)

2008-06-01T00:00:00Z

Aims: Studies reporting improved left ventricular (LV) function of percutaneous skeletal myoblast (SkM) injection in patients with ischaemic cardiomyopathy had follow-up not exceeding 12 months, and did not include a control group. Our group has reported evidence for myoblast efficacy in the first five out of the 14 treated patients. The objective of the present evaluation was to assess if these effects were sustained at long-term follow-up. We compared function of patients treated with SkM 4 years earlier with a matched control group. Secondary endpoints included mortality, NYHA class, N-terminal pro-B-natriuretic peptide levels, incidence of arrhythmias, and quality of life. Methods and results: Fourteen patients with ischaemic cardiomyopathy who underwent SkM injection were compared with 28 non-randomized control patients matched for age, sex, location, and extent of myocardial infarction. Contrast echocardiography and tissue Doppler imaging (TDI) was performed to compare global and regional LV function. At 4-year follow-up, three patients (21%) had died in the treated group and 11 patients (39%) in the control group (P = 0.8). In the survivors, LV ejection fraction (EF) was 35 ± 10% and 37 ± 9% in the SkM group and 36 ± 8% and 36 ± 6% in the controls at baseline and 4 years follow-up, respectively (P = 0.96 between groups at follow-up). TDI-derived systolic velocity in the injected sites was 5.4 ± 1.8 cm/s in the SkM group when compared with 5.1 ± 1.6 cm/s in corresponding sites in the control group (P = 0.47). None of the secondary endpoints showed a difference between the groups. However, in the patients fitted with an internal cardioverter defibrillator, more arrhythmias leading to interventions occurred in the treated group than in the control group, 87% and 13%, respectively (P = 0.015). Conclusion: Percutaneous intramyocardial SkM injection in ischaemic cardiomyopathy has no sustained positive effect on resting global or regional LV function, respectively, at 4-year follow-up. Moreover, the procedure may induce a higher risk of developing serious arrhythmias, but larger patient series are required before more precise characterization of the safety and efficacy profile of the procedure is possible.

Effect of Successful Alcohol Septal Ablation on Microvascular Function in Patients With Obstructive Hypertrophic Cardiomyopathy (Article)

2008-05-01T00:00:00Z

We hypothesized that relief of obstruction in patients with hypertrophic cardiomyopathy (HC) by percutaneous transluminal septal myocardial ablation (PTSMA) improves microvascular dysfunction by relief of extravascular compression. Microvascular dysfunction in obstructive HC is related to extravascular compression by increased left ventricular (LV) mass and LV end-diastolic pressure. The study included 14 patients with obstructive HC (mean age 55 ± 12 years, 11 men) who underwent successful PTSMA and 14 healthy volunteers (mean age 31 ± 4 years, 11 men). LV hemodynamics (by Doppler echocardiography) and intramyocardial flow dynamics (by adenosine myocardial contrast echocardiography) were evaluated in healthy volunteers and before and 6 months after PTSMA in patients with HC. LV end-diastolic pressure was estimated from the ratio of transmitral early LV filling velocity to early diastolic mitral annular velocity. PTSMA reduced the invasively measured LV outflow tract gradient (119 ± 35 vs 17 ± 16 mm Hg, p <0.0001) and LV end-diastolic pressure (23 ± 3 vs 16 ± 2 mm Hg, p <0.001). Six months after PTSMA, myocardial flow reserve improved (2.73 ± 0.56 vs 3.21 ± 0.49, p <0.001), but did not normalize compared with healthy controls (vs 3.95 ± 0.77, p <0.001). Also, septal hyperemic endo-to-epi myocardial blood flow ratio improved (0.70 ± 0.11 vs 0.92 ± 0.07, p <0.001). Changes in LV end-diastolic pressure, LV mass index, and LV outflow tract peak systolic gradient correlated well with changes in hyperemic perfusion (all p <0.05). In conclusion, microvascular dysfunction improves after PTSMA due to relief of extravascular compression forces.

Usefulness of Clinical, Echocardiographic, and Procedural Characteristics to Predict Outcome After Percutaneous Transluminal Septal Myocardial Ablation (Article)

2008-05-01T00:00:00Z

This study was conducted to assess outcomes after percutaneous transluminal septal myocardial ablation (PTSMA) treatment in 131 patients (mean age 56 ± 16 years) with obstructive hypertrophic cardiomyopathy. In-hospital and follow-up complications as well as late PTSMA failure (defined as unsatisfactory clinical outcome and a significant residual outflow tract gradient, necessitating reintervention) were noted. Baseline clinical, echocardiographic, and PTSMA characteristics were examined as determinants of outcomes. Also, the effect of ethanol volume and the role of a learning curve were investigated. PTSMA was successful in 90% of the patients. In-hospital and follow-up cardiac events were noted in 20 patients, including cardiac death (in-hospital n = 4, follow-up n = 1), acute myocardial infarction due to ethanol leakage (n = 1), coronary dissection (n = 2), nonfatal cardiac tamponade (n = 1), and permanent pacemaker (n = 6) or cardiac defibrillator (in-hospital n = 4, follow-up n = 1) implantation. Late PTSMA failure was noted in 12 patients. All baseline characteristics were comparable between successful and failed PTSMA. Ethanol volume was related to peak creatinine kinase value (p <0.0001) but not to late PTSMA failure or greater need for pacemaker implantation. Late PTSMA failure occurred more frequently in PTSMA procedures performed in the early, less experienced time period (p <0.001). In conclusion, this study confirms that PTSMA, although effective, has a relatively high complication rate. Late PTSMA failure could not be predicted by baseline characteristics but could partially be explained by a learning-curve effect. This finding implies that PTSMA procedures should be restricted to experienced centers.

Reverse of Left Ventricular Volumetric and Structural Remodeling in Heart Failure Patients Treated With Cardiac Resynchronization Therapy (Article)

2008-03-01T00:00:00Z

Patients with heart failure and mechanical dyssynchrony suffer a progressive increase in left ventricular (LV) mass and asymmetrical regional hypertrophy with eventual poor prognosis. The present study sought to investigate whether cardiac resynchronization therapy (CRT) could reverse these abnormalities. The study included 66 consecutive heart failure patients who received CRT. All patients underwent serial evaluation before, 3 months after, and 12 months after CRT. At 12 months after CRT, 50 patients (76%) were echocardiographic volumetric responders, defined as a >15% reduction in LV end-systolic volume. LV end-systolic volume was decreased from 214 ± 97 ml to 179 ± 88 ml at 3 months and was further decreased to 158 ± 86 ml at 12 months after CRT (all p <0.01). LV ejection fraction was improved from 18% ± 4% to 28% ± 7% (p <0.001) at 3 months without further change at 12 months after CRT. LV mass was reduced from 242 ± 52 g to 222 ± 45 g at 3 months and was further reduced to 206 ± 50 g at 12 months after CRT (all p <0.01). Improvement of LV geometry was seen as improvements of the end-diastolic (1.64 ± 0.14 vs 1.77 ± 0.17, p <0.001) and the end-systolic (1.63 ± 0.14 vs 1.99 ± 0.22, p <0.001) sphericity indexes, respectively, at 3 months, without further significant changes at 12 months after CRT. Volumetric responders had a reduction in LV mass from 240 ± 50 to 210 ± 38 at 3 months, and LV mass was further reduced to 186 ± 37 g at 12 months after CRT (all p <0.01). In contrast, nonresponders had a progressive increase in LV mass from 248 ± 59 g to 258 ± 54 g at 3 months, and LV mass was further increased to 269 ± 60 g at 12 months after CRT (all p <0.05). Likewise, only in volumetric responders, regression of the asymmetric hypertrophy of the lateral wall was noted. In conclusion, CRT results in not only volumetric improvement but also in true reverse LV structural remodeling, evidenced by progressive reduction in LV mass and restoration of regional wall symmetry.

Assessment of left ventricular ejection fraction after myocardial infarction using contrast echocardiography (Article)

2008-03-01T00:00:00Z

Aims: Despite its relatively high intra- and inter-observer variability for left ventricular ejection fraction (LV-EF) echocardiography is clinically still the most used modality to assess LV-EF. We studied whether adding a second-generation microbubble contrast agent could decrease this variability. Methods and results: Forty-eight patients underwent transthoracic echocardiography in second-harmonic mode (SHI) with and without contrast within 5 days after an acute myocardial infarction. LV-EF was determined using the Simpson's biplane method. With contrast intra-observer variability decreased from 12.5 ± 11.5% to 7.0 ± 7.0% (P < 0.001) and inter-observer variability decreased from 16.9 ± 9.9% to 7.0 ± 6.2% (P < 0.001). Bland-Altman analysis confirmed these findings by demonstrating smaller 95% limits of agreement for both the intra- and inter-observer variability when contrast was used. This improvement in intra- and inter-observer variability was seen to a comparable extent in patients with moderate-to-poor and good quality SHI echocardiograms. Conclusion: Echo contrast significantly improves intra- and inter-observer variability for LV-EF, both in patients with moderate-to-poor and good quality SHI echocardiograms.

Assessment of left atrial volume and function by real-time three-dimensional echocardiography (Article)

2008-01-11T00:00:00Z

Background: Determination of left atrial (LA) size and function is important in clinical decision-making. Calculation of LA volume (LAV) is the most accurate index of LA size. Aim: To compare real-time 3-dimensional echocardiography (RT3DE) and 2-dimensional echocardiography (2DE) for calculation of LAV and function. Methods: Fifty patients were studied using 2DE and RT3DE for calculating LAV including: Maximum (V max), minimum (V min) and pre-atrial contraction (V pre A) volumes. For 2DE, the formula: LAV = 8(A1) (A2)/3π (L) was used, while for RT3DE, offline analysis was performed using commercially available software. LA function indices including Total Atrial Stroke Volume (TASV), active ASV (AASV), Total Atrial Emptying Fraction (TAEF), active AEF (AAEF), passive AEF (PAEF), and Atrial Expansion Index (AEI) were calculated. Results: Patients were classified into 2 equal groups: group I with normal V max (< 50 ml) and group II with V max (≥ 50 ml). Good correlation was obtained between RT3DE and 2DE for LAV (r = 0.64, p = 0.001) in group I and (r = 0.83, p < 0.0001) in group II. In group I, LAV and functions showed no significant difference by both techniques, while in group II, the V min and V pre A were significantly lower by RT3DE than 2DE (p = 0.009, 0.006). TAEF, AEI, and PAEF indices were significantly higher by RT3DE than 2DE in group II. Conclusion: RT3DE provides a reproducible assessment of active and passive LA function by volumetric cyclic changes. It is comparable and may be superior to 2DE due to its higher sensitivity to volume changes.

Predictors of Cardiac Events After Cardiac Resynchronization Therapy With Tissue Doppler-Derived Parameters (Article)

2007-12-01T00:00:00Z

Background: To evaluate the prognostic value of tissue Doppler imaging (TDI)-derived parameters (E/E′ ratio and Tei index) in heart failure (HF) patients who underwent cardiac resynchronization therapy (CRT). Methods and Results: The study comprised 74 consecutive HF patients (mean age 60 ± 11 years) who underwent CRT. Echocardiography including TDI measurements was performed in all patients at baseline and 3 months after CRT. During a median follow-up period of 720 days (range 210 to 1020 days), 21 patients (28%) had events (8 deaths, and hospitalization for HF in the remaining 13). From the baseline clinical and echocardiography data, univariable Cox-regressions analysis revealed that only diabetes (hazard ratio [HR] 3.703, P < .01), E/A ratio (HR 3.492, P < .001), and E/E′ ratio (HR 1.130, P < .001) were predictors for cardiac events. From the 3-month follow-up data, the E/A ratio (HR 2.988, P < .005), E/E′ ratio (HR 1.170, P < .001), left ventricular ejection fraction (HR 0.835, P < .01), deceleration time (HR 0.977, P < .05), and the Tei index (HR 15.784, P < .001) were predictors for cardiac events. After multivariable analysis, only diabetes (HR 5.544, P < .05), the 3-month E/E′ ratio (HR 1.229, P < .001), and change in Tei index (HR 32.174, P < .001) were independent predictors for cardiac events. Patients with a high baseline and 3-month follow-up E/E′ ratio had an 88% cardiac event rate. Conclusions: The Tei index and E/E′ ratio are independent predictors of poor response and cardiac events after CRT.

Role of parasternal data acquisition during contrast enhanced real-time three-dimensional echocardiography (Article)

2007-11-01T00:00:00Z

Background: Recent technical developments have resulted in high-resolution real time three-dimensional echocardiography (RT3DE). The purpose of this study was to investigate the beneficial role of parasternal-acquired images in addition to apical-acquired images during contrast stress RT3DE. Methods: The study comprised 30 consecutive patients (52 ± 11 years, 18 males) with chest pain referred for routine stress testing. The contrast RT3DE images were acquired from the apical and parasternal window with a Sonos 7500 echo system attached to a X4 matrix array transducer. Results: From the apical and parasternal acquisition, 464 segments (91%) and 267 segments (52%) could be analyzed, respectively (P < 0.001). From the apical window, more basal segments were not analyzable (22 of 180, 12% vs. 24 of 330, 7%; P = 0.06). From the parasternal window, more apical segments were not analyzable (117 of 150, 78% vs. 126 of 360, 35%; P < 0.01). The mean image quality index of the 464 analyzable segments from the apical-acquired images was 2.43. Fourteen of 180 basal segments (8%), 12 of 180 midventricular segments (7%) and 2 of 150 apical segment (1%) were only available with parasternal data acquisition. In addition to these 28 segments, 79 segments (15%) already visualized from the apical window improved in quality. The overall mean image quality index, now assessed from 492 (96%) of all segments, using both the apical and parasternal acquired data, improved to 2.74 (P < 0.05). Conclusions: Addition of parasternal to apical acquisition of contrast RT3DE data can decrease the number of nonvisualized segments and improve mean image quality.

Comparison of Contrast Agent-Enhanced Versus Non-Contrast Agent-Enhanced Real-Time Three-Dimensional Echocardiography for Analysis of Left Ventricular Systolic Function (Article)

2007-11-01T00:00:00Z

Ultrasound contrast has shown to improve endocardial border definition. The purpose of this study was to evaluate the value of contrast agent-enhanced versus non-contrast agent-enhanced real-time 3-dimensional echocardiography (RT3DE) for the assessment of left ventricular (LV) volumes and ejection fraction. Thirty-nine unselected patients underwent RT3DE with and without SonoVue contrast agent enhancement and magnetic resonance imaging (MRI) on the same day. An image quality index was calculated by grading all 16 individual LV segments on a scale of 0 to 4: 0, not visible; 1, poor; 2, moderate; 3, good; and 4, excellent. The 3-dimensional data sets were analyzed offline using dedicated TomTec analysis software. By manual tracing, LV end-systolic volume, LV end-diastolic volume, and LV ejection fraction were calculated. After contrast agent enhancement, mean image quality index improved from 2.4 ± 1.0 to 3.0 ± 0.9 (p <0.001). Contrast agent-enhanced RT3DE measurements showed better correlation with MRI (LV end-diastolic volume, r = 0.97 vs 0.86; LV end-systolic volume, r = 0.96 vs 0.94; LV ejection fraction, r = 0.94 vs 0.81). The limits of agreement (Bland-Altman analysis) showed a similar bias for RT3DE images with and without contrast agent but with smaller limits of agreement for contrast agent-enhanced RT3DE. Also, inter- and intraobserver variabilities decreased. In a subgroup, patients with poor to moderate image quality showed an improvement in agreement after administration of contrast agent (±24.4% to ±12.7%) to the same level as patients with moderate to good image quality without contrast agent (±10.4%). In conclusion, contrast agent-enhanced RT3DE is more accurate in assessment of LV function as evidenced by better correlation and narrower limits of agreement compared with MRI, as well as lower intra- and interobserver variabilities.

A comparison between QLAB and tomtec full volume reconstruction for real time three-dimensional echocardiographic quantification of left ventricular volumes (Article)

2007-10-01T00:00:00Z

Objectives: To compare the interobserver variability and accuracy of two different real time three-dimensional echocardiography (RT3DE) analyzing programs. Methods: Forty-one patients (mean age 56 ± 11 years, 28 men) in sinus rhythm with a cardiomyopathy and adequate 2D image quality underwent RT3DE and magnetic resonance imaging (MRI) within one day. Off-line left ventricular (LV) volume analysis was performed with QLAB V4.2 (semiautomated border detection with biplane projections) and TomTec 4D LV analysis V2.0 (primarily manual tracking with triplane projections and semiautomated border detection). Results: Excellent correlations (R2> 0.98) were found between MRI and RT3DE. Bland-Altman analysis revealed an underestimated LV end-diastolic volume (LV-EDV) for both TomTec (-9.4 ± 8.7 mL) and QLAB (-16.4 ± 13.1 ml). Also, an underestimated LV end-systolic volume (LV-ESV) for both TomTec (-4.8 ± 9.9 mL) and QLAB (-8.5 ± 14.2 mL) was found. LV-EDV and LV-ESV were significantly more underestimated with QLAB software. Both programs accurately calculated LV ejection fraction (LV-EF) without a bias. Interobserver variability was 6.4 ± 7.8% vs. 12.2 ± 10.1% for LV-EDV, 7.8 ± 9.7% vs. 13.6 ± 11.2% for LV-ESV, and 7.1 ± 6.9% vs. 9.7 ± 8.8% for LV-EF for TomTec vs. QLAB, respectively. The analysis time was shorter with QLAB (4 ± 2 minutes vs. 6 ± 2 minutes, P < 0.05). Conclusions: RT3DE with TomTec or QLAB software analysis provides accurate LV-EF assessment in cardiomyopathic patients with distorted LV geometry and adequate 2D image quality. However, LV volumes may be somewhat more underestimated with the current QLAB software version.

Cardiac abnormalities in adults with the attenuated form of mucopolysaccharidosis type I (Article)

2007-10-01T00:00:00Z

Background: Cardiac involvement in mucopolysaccharidosis type I (MPS I) has been studied primarily in its most severe forms. Cardiac involvement, particularly left ventricular (LV) systolic and diastolic function, in the attenuated form of MPS I is less well known. Methods: Cardiac function was prospectively investigated in 9 adult patients with the attenuated form of MPS I. All patients underwent 12-lead electrocardiography, 24 h Holter monitoring and two-dimensional echocardiography including tissue Doppler imaging (TDI). Eighteen age- and sex-matched healthy volunteers served as a control group. Results: Aortic, mitral and tricuspid valve thickening was seen in, respectively, 5 (56%), 4 (44%) and 2 (22%) patients. Moderate mitral valve stenosis was seen in 1 patient and moderate aortic stenosis in 2 patients. All patients had mild-to-moderate aortic and mitral valve regurgitation and 6 patients (67%) had mild-to-moderate tricuspid valve regurgitation. Despite normal LV dimensions, ejection fraction and mass index, MPS patients had lower mean systolic mitral annular velocities (6.1±0.6 vs 9.1±1.4 cm/s, p<0.01) compared to normal control subjects. Similarly, mean early diastolic mitral annular velocities were lower in MPS patients (7.8±0.9 vs 13.3±3.3 cm/s, p<0.01). Conclusion: MPS I patients with the attenuated phenotype have not only valvular abnormalities but also LV diastolic and systolic abnormalities.

Real-time 3-Dimensional Contrast Stress Echocardiography: A Bridge Too Far? (Article)

2007-10-01T00:00:00Z

Assessment of intravascular and extravascular mechanisms of myocardial perfusion abnormalities in obstructive hypertrophic cardiomyopathy by myocardial contrast echocardiography (Article)

2007-10-01T00:00:00Z

Objectives: To assess mechanisms of myocardial perfusion impairment in patients with hypertrophic cardiomyopathy (HCM). Methods: Fourteen patients with obstructive HCM (mean (SD) age 53 (10) years, 11 men) underwent intravenous adenosine myocardial contrast echocardiography (MCE), positron emission tomography (PET) and cardiac catheterisation. Fourteen healthy volunteers (mean age 31 (4) years, 11 men) served as controls. Relative myocardial blood volume (rBV), exchange flow velocity (β), myocardial blood flow (MBF), MBF reserve (MFR) and endocardial-to-subepicardial (endo-to-epi) MBF ratio were measured from the steady state and contrast replenishment time-intensity curves. Results: Patients with HCM had lower rest MBF (for LVRPP-corrected) - mean (SD) (0.92 (0.12) vs 1.13 (0.25) ml/min/g, p<0.01) - and hyperaemic MBF - (2.56 (0.49) vs 4.34 (0.78) ml/min/g, p<0.01) than controls. Resting rBV was lower in patients with HCM (0.094 (0.016) vs 0.138 (0.014) ml/ml), and during hyperaemia (0.104 (0.018) ml/ml vs 0.185 (0.024) ml/ml) (all p<0.001) than in controls. β tended to be higher in HCM at rest (9.4 (4.6) vs 7.7 (4.2) ml/min) and during hyperaemia (25.8 (6.4) vs 23.1 (6.2) ml/min) than in controls. Septal endo-to-epi MBF decreased during hyperaemia (0.86 (0.15) to 0.64 (0.18), p<0.01). rBV was inversely correlated with left ventricular (LV) mass index (p<0.05). Both hyperaemic and endo-to-epi MBF were inversely correlated with LV end-diastolic pressure, LV mass index, and LV outflow tract pressure gradient (all p<0.05). MCE-derived MBF correlated well with PET at rest (r=0.84) and hyperaemia (r=0.87) (all p<0.001). Conclusions: In patients with HCM, LV end-diastolic pressure, LV outflow tract pressure gradient, and LV mass index are independent predictors of rBV and hyperaemic MBF.

Quantification of Left Ventricular Volumes and Function in Patients with Cardiomyopathies by Real-time Three-dimensional Echocardiography: A Head-to-Head Comparison Between Two Different Semiautomated Endocardial Border Detection Algorithms (Article)

2007-09-01T00:00:00Z

Objective: We evaluated two different commercially available real-time 3-dimensional echocardiographic semiautomated border detection algorithms for left ventricular (LV) volume analysis in patients with cardiomyopathy and distorted LV geometry. Methods: A total of 53 patients in sinus rhythm with various types of cardiomyopathy (mean age 56 ± 11 years, 28 men) and adequate 2-dimensional image quality were included. The real-time 3-dimensional echocardiographic multiplane interpolation (MI) and full volume reconstruction (FVR) methods were used for LV volume analysis. Magnetic resonance imaging was used as the reference method. Results: A strong correlation (R2> 0.95) was found for all LV volume and ejection fraction measurements by either real-time 3-dimensional echocardiographic method. Analysis time was shorter with the FVR method (6 ± 2 vs 15 ± 4 minutes, P < .01) as compared with the MI method. Bland-Altman analysis showed greater underestimation of end-diastolic and end-systolic volumes by MI compared with FVR. For the MI method a bias of -24.0 mL (-15.0% of the mean) for end-diastolic volume and -11.3 mL (-18.0% of the mean) for end-systolic volume was found. For FVR analysis these values were -9.9 mL (-6.0% of the mean) and -5.0 mL (-9.0% of the mean), respectively. Ejection fraction was similar for the MI and FVR method with a mean difference compared with magnetic resonance imaging of 0.6 (1.0%) and 0.8 (1.3%), respectively. Conclusion: In patients with cardiomyopathy, distorted LV geometry, and good 2-dimensional image quality, the FVR method is faster and more accurate than the MI method in assessment of LV volumes.

Baseline Predictors of Cardiac Events After Cardiac Resynchronization Therapy in Patients With Heart Failure Secondary to Ischemic or Nonischemic Etiology (Article)

2007-08-01T00:00:00Z

We evaluated the value of baseline parameters derived from tissue Doppler imaging (TDI) for event prediction in patients with heart failure (HF) secondary to ischemic and nonischemic cause who underwent cardiac resynchronization therapy (CRT). Seventy-four consecutive patients with HF (mean age 59 ± 11 years) underwent CRT. Baseline clinical parameters included New York Heart Association class, 6-minute walking distance, HF cause, and diabetes. TDI-derived parameters included lateral and septal E/E′ ratios defined as peak early left ventricular (LV) filling velocity (E wave) to TDI-derived peak early diastolic velocity of the mitral annulus (E′ wave). During a median follow-up of 720 days, 21 patients (28%) had cardiac death or hospitalization for HF. These patients more often had an ischemic cause (p <0.05), diabetes (p <0.05), and restrictive filling (p <0.001), less often had LV dyssynchrony (p <0.05), and had higher septal and lateral E/E′ ratios (p <0.001 for the 2 comparisons). In a multivariable model using a forward selection algorithm, only the lateral E/E′ ratio remained an independent predictor of cardiac outcome. After 3 months of CRT, TDI-derived systolic mitral annular systolic and diastolic velocities improved significantly in nonischemic patients for the septal and lateral sides. In contrast, in ischemic patients no significant improvements were seen. Significant improvements were seen in septal and lateral E/E′ ratios in ischemic and nonischemic patients. However, the improvement in lateral E/E′ ratio was significantly less and absolute 3-months E/E′ ratios were worse in ischemic patients. In conclusion, baseline lateral E/E′ ratio is an independent predictor for cardiac events in patients with HF treated with CRT. The worse clinical outcome in ischemic patients may be due to failure of improvement in systolic and diastolic mitral annular velocities after CRT, resulting in a less pronounced improvement in LV filling pressures as demonstrated by this E/E′ ratio.

Assessment of Left Atrial Ejection Force in Hypertrophic Cardiomyopathy Using Real-time Three-dimensional Echocardiography (Article)

2007-06-01T00:00:00Z

The study included 30 patients with hypertrophic cardiomyopathy (HCM) (obstructive and nonobstructive) and 15 control subjects. End-diastolic mitral annulus area (MAA3D) and mitral valve area (MVA3D) were measured by real-time 3-dimensional (3D) echocardiography. MVA2Dand peak mitral inflow A wave velocity (V) were measured by 2-dimensional (2D) echocardiography. Left atrial ejection force (LA-EF) was calculated by 2D echocardiography and real-time 3D echocardiography using the formula: 0.5 × 1.06 × (MAA or MVA) × V2, where (1.06) is blood viscosity. LA-EF2D-MVA, LA-EF3D-MVA, LA-EF3D-MAA, and V were significantly higher in patients with HCM than control subjects (P < .001). LA-EF2D-MVAand LA-EF3D-MVAwere lower than LA-EF3D-MAAin HCM only (P < .001). In obstructive HCM, LA-EF2D-MVA, LA-EF3D-MVA, LA-EF3D-MAA, and V were significantly higher than in nonobstructive HCM (P < .05). Left ventricular outflow tract gradient contributed independently to high LA-EF in obstructive HCM. We concluded that HCM is associated with higher LA-EF than normal, and higher in obstructive HCM than nonobstructive indicating a higher atrial workload that is reflected by LA-EF3D-MAA.

Real-time three-dimensional echocardiography for regional evaluation of aortic stiffness (Article)

2007-03-01T00:00:00Z

Aortic stiffness is an important predictor of cardiovascular morbidity and mortality. Non-invasive measurement of aortic stiffness is a promising challenge for echocardiography. The most important limitation of previous studies was that regional differences for aortic stiffness were not taken into consideration. In our patient, we demonstrated the usefulness of real-time three-dimensional echocardiography in assessment of regional aortic stiffness.

Spectral pulsed-wave tissue Doppler imaging lateral-to-septal delay fails to predict clinical or echocardiographic outcome after cardiac resynchronization therapy (Article)

2007-02-01T00:00:00Z

Aims: The current study sought to assess if pre-implantation lateral-to-septal delay (LSD) ≥60 ms assessed by spectral pulsed-wave myocardial tissue Doppler imaging (PW-TDI) could predict successful long-term outcome after cardiac resynchronization therapy (CRT). Methods and results Sixty patients (72% males, mean age 59 ± 10 years) who were referred for CRT according to the ACC/ESC guidelines were enrolled in the study. All patients underwent spectral PW-TDI before and 1 year after CRT. Two left ventricular (LV) dyssynchrony time intervals, TOand TP(time to onset and peak of LV myocardial velocity, respectively), LSD were recorded. Left ventricular dyssynchrony was defined as LSD ≥60 ms. Clinical response was defined as an improvement in >1 NYHA class plus improvement in 6-min walk distance (6MWD) ≥25%, echocardiographic response was defined as a ≥15% reduction in LV end-systolic volume (LV-ESV). One year after CRT, 50 patients (83%) were clinical responders and 47 patients (78%) were echocardiographic responders. Both TOand TPLV dyssynchrony indices failed to predict echocardiographic CRT outcome. In addition, there were no significant differences between 'synchronous' and 'dyssynchronous' patient populations at baseline or follow-up in either clinical (NYHA class and 6MWD) or echocardiographic (LV ejection fraction, LV end-diastolic, and end-systolic) variables. Conclusion: The great majority of patients referred for CRT benefit clinically from it. However, spectral PW-TDI failed to predict CRT outcome. When PW-TDI dyssynchrony was applied for selection of proper CRT patients, up to 80-86% of the patients with synchronous LSD that had proven clinical and echocardiographic benefit from CRT would have been denied CRT.

Cardiac Involvement in Adults With m.3243A>G MELAS Gene Mutation (Article)

2007-01-15T00:00:00Z

Cardiac data in adults with mitochondrial encephalomyopathy, lactic acidosis, and strokelike episodes (MELAS syndrome) or asymptomatic gene carriers with the mitochondrial deoxyribonucleic acid adenine-to-guanine point mutation at nucleotide pair 3243 are scarce. Twelve subjects (mean age 35 ± 13 years), 8 with MELAS syndrome (patients) and 4 asymptomatic gene carriers (carriers), were enrolled in the study. Each subject underwent electrocardiography, exercise testing, Holter monitoring, echocardiography, and genetic and biochemical analysis for respiratory chain enzyme activity (complex I rest activity) in skeletal muscle. On electrocardiography and Holter monitoring, none of the subjects had evidence of preexcitation, cardiac arrhythmias, or conduction abnormalities. Patients had significantly lower (42 ± 17% from normal vs 103 ± 14%, p <0.02) exercise tolerance. All but 1 of the patients and none of the gene carriers had ragged red fibers on muscle biopsy. The mean percentage of gene mutation in skeletal muscle tended to be higher in patients (53 ± 19%, range 19% to 73%) compared with carriers (33 ± 20%, range 15% to 62%). Mean complex I rest activity in patients (36 ± 18%, range 10% to 58%) was significantly (p <0.01) lower compared with carriers (120 ± 60%, range 72% to 205%). Left ventricular (LV) abnormalities were confined to patients with MELAS syndrome. Two patients had LV hypertrophy, 5 had LV systolic abnormalities, and 5 had LV diastolic dysfunction. Apart from 1 patient with an isolated LV diastolic abnormality, all patients with LV abnormalities had ragged red fibers. Patients with abnormal systolic LV function had a trend toward a higher percentage of mutated skeletal muscle (59.7 ± 10.7% vs 35.8 ± 21.3%, p <0.10) and significantly lower complex I rest activity (26.7 ± 14.0% vs 97.8% ± 57.9, p <0.01). In conclusion, none of the MELAS gene carriers had cardiac abnormalities, whereas most patients with the MELAS phenotype, particularly those with ragged red fibers, had LV involvement.

Usefulness of Ultrasound Contrast Agent to Improve Image Quality During Real-Time Three-Dimensional Stress Echocardiography (Article)

2007-01-15T00:00:00Z

Dobutamine stress echocardiography is an accepted tool for the diagnosis of coronary artery disease. Some investigators have claimed that 3-dimensional imaging improves the diagnostic accuracy of dobutamine stress echocardiography. The purpose of the present investigation was to examine the role of contrast echocardiography in the improvement of segmental quality and interobserver agreement during stress real-time 3-dimensional echocardiography (RT3DE). The study comprised 36 consecutive patients with stable chest pain referred for routine stress testing. Three-dimensional images were acquired with an RT3DE system with an X4 matrix-array transducer. All available reconstructed 2-dimensional segments were graded as optimal, good, moderate, or poor. Wall motion was scored as normal, mild hypokinesia, severe hypokinesia, akinesia, or dyskinesia. At peak stress, 466 of the 612 segments (76%) could be analyzed during conventional RT3DE. With contrast-enhanced RT3DE, the number of available segments increased to 553 (90%). The image quality index during conventional RT3DE was 2.2, whereas with contrast-enhanced RT3DE, it was 3.1. With conventional RT3DE, 2 independent observers agreed on the diagnosis of myocardial ischemia in 85 of 108 coronary territories (79%, κ = 0.26). With contrast-enhanced RT3DE, agreement increased to 95 of 108 coronary territories (88%, κ = 0.59). Study agreement on myocardial ischemia was present in 26 of 36 studies (72%, κ = 0.43) with conventional RT3DE and in 32 of 36 studies (89%, κ = 0.77) with contrast-enhanced RT3DE. In conclusion, during stress RT3DE, contrast-enhanced imaging significantly decreases the number of poorly visualized myocardial segments and improves interobserver agreement for the diagnosis of myocardial ischemia.

Sustained improvement after combined anterior mitral leaflet extension and myectomy in hypertrophic obstructive cardiomyopathy. (Article)

2003-10-28T00:00:00Z

BACKGROUND: Mitral leaflet extension (MLE) combined with septal myectomy is a new surgical approach to treat hypertrophic obstructive cardiomyopathy (HOCM) and an enlarged mitral leaflet area. The study presents the long-term clinical results and outcome of this technique. METHODS AND RESULTS: MLE entails grafting a glutaraldehyde-preserved autologous pericardial patch onto the center portion of the anterior mitral valve leaflet. Twenty-nine patients with HOCM were studied. Mean follow-up (+/-SD) was 3.4+/-2.1 years (range 3 months to 7.7 years). The preoperative calculated mitral leaflet area was 16.7+/-3.4 cm2. New York Heart Association functional class improved significantly from 2.8+/-0.4 to 1.3+/-0.4 (P<0.05), width of the interventricular septum decreased from 23+/-4 to 17+/-2 mm (P<0.05), left ventricular outflow tract gradient decreased from 100+/-20 to 17+/-14 mm Hg (P<0.01), severity of mitral regurgitation graded on a scale from 0 to 4+ decreased from 2.5+/-0.9 to 0.5+/-0.6 (P<0.01), and severity of the systolic anterior motion of the mitral valve graded on a scale from 0 to 3+ decreased from 2.9+/-0.3 to 0.5+/-0.7 (P<0.01) postoperatively. There were no deaths associated with surgery. CONCLUSIONS: Long-term follow-up shows sustained improvement in functional status, reduction of outflow tract obstruction, and attenuation of mitral regurgitation and systolic anterior motion of the mitral valve. In this respect, the new technique widens the surgical applications in HOCM.

Preload dependence of new Doppler techniques limits their utility for left ventricular diastolic function assessment in hemodialysis patients (Article)

2003-01-01T00:00:00Z

Left ventricular (LV) hypertrophy leads to diastolic dysfunction. Standard Doppler transmitral and pulmonary vein (PV) flow velocity measurements are preload dependent. New techniques such as mitral annulus velocity by Doppler tissue imaging (DTI) and LV inflow propagation velocity measured from color M-mode have been proposed as relatively preload-independent measurements of diastolic function. These parameters were studied before and after hemodialysis (HD) with ultrafiltration to test their potential advantage for LV diastolic function assessment in HD patients. Ten patients (seven with LV hypertrophy) underwent Doppler echocardiography 1 h before, 1 h after, and 1 d after HD. Early (E) and atrial (A) peak transmitral flow velocities, peak PV systolic (s) and diastolic (d) flow velocities, peak e and a mitral annulus velocities in DTI, and early diastolic LV flow propagation velocity (V(p)) were measured. In all patients, the E/A ratio after HD (0.54; 0.37 to 1.02) was lower (P < 0.01) than before HD (0.77; 0.60 to 1.34). E decreased (P < 0.01), whereas A did not. PV s/d after HD (2.15; 1.08 to 3.90) was higher (P < 0.01) than before HD (1.80; 1.25 to 2.68). Tissue e/a after HD (0.40; 0.26 to 0.96) was lower (P < 0.01) than before HD (0.56; 0.40 to 1.05). Tissue e decreased (P < 0.02), whereas a did not. V(p) after HD (30 cm/s; 16 to 47 cm/s) was lower (P < 0.01) than before HD (45 cm/s; 32 to 60 cm/s). Twenty-four hours after the initial measurements values for E/A (0.59; 0.37 to 1.23), PV s/d (1.85; 1.07 to 3.38), e/a (0.41; 0.27 to 1.06), and V(p) (28 cm/s; 23 to 33 cm/s) were similar as those taken 1 h after HD. It is concluded that, even when using the newer Doppler techniques DTI and color M-mode, pseudonormalization, which was due to volume overload before HD, resulted in underestimation of the degree of diastolic dysfunction. Therefore, the advantage of these techniques over conventional parameters for the assessment of LV diastolic function in HD patients is limited. Assessment of LV diastolic function should not be performed shortly before HD, and its time relation to HD is essential.

Clinical utility and cost effectiveness of a personal ultrasound imager for cardiac evaluation during consultation rounds in patients with suspected cardiac disease (Article)

2003-01-01T00:00:00Z

OBJECTIVE: To assess the clinical utility and cost effectiveness of a personal ultrasound imager (PUI) during consultation rounds for cardiac evaluation of patients with suspected cardiac disease. METHODS: 107 unselected patients from non-cardiac departments (55% men) were enrolled in the study. After the physical examination the consultant cardiologist performed an echocardiographic study with a PUI. The final report was given instantly to the referring physician. All patients subsequently underwent a study with a standard echocardiographic device (SED). For each patient the consultant cardiologist noted whether the findings of the PUI were adequate for final diagnosis. The total cost when full echocardiography was used was compared with the cost when the PUI was used. The time interval from request to diagnosis was also compared. RESULTS: In 84 (78.5%) patients no further examination with an SED was regarded as necessary. Twenty three patients (21.5%) required a further detailed examination with the SED because of the need for haemodynamic information. There was an excellent agreement for the detection of abnormalities between the two devices (96%). The total cost was euro;132 per patient with the SED and euro;75 per patient with the PUI. According to this study, the use of the PUI can lead to a 33.4% reduction of total cost. The mean time from request to diagnosis at the authors' institution was four days for the SED and instantly for the PUI, for additional potential cost savings. CONCLUSIONS: Immediate echocardiographic assessment during consultation rounds can lead to significant cost savings and can shorten the time to diagnosis.

Doppler tissue velocity sampling improves diagnostic accuracy during dobutamine stress echocardiography for the assessment of viable myocardium in patients with severe left ventricular dysfunction. (Article)

2000-07-01T00:00:00Z

BACKGROUND: Both nuclear imaging with F18-fluorodeoxyglucose and dobutamine stress echocardiography have been used to identify viable myocardium, although dobutamine-stress echocardiography has been demonstrated to be the less sensitive of the two. AIM: To compare the accuracy of pulsed-wave Doppler tissue sampling with dobutamine-stress echocardiography for the detection of viable myocardium, using F18-fluorodeoxyglucose imaging as a reference. Methods Forty patients with chronic coronary artery disease and left ventricular dysfunction (mean ejection fraction 33+/-11%), underwent F18-fluorodeoxyglucose imaging, dobutamine-stress echocardiography and pulsed-wave Doppler tissue sampling. Evaluation was performed using a six-segment model. RESULTS: Visual assessment by resting echo was feasible in 230 out of 240 segments (96%); 177 (77%) segments showed severe dyssynergy at rest. F18-fluorodeoxyglucose imaging showed viability in 95 (54%) segments while 82 (46%) were non-viable. Ejection phase velocity at rest was not significantly different; ejection velocities during low-dose and peak-dose dobutamine, however, were significantly higher in viable myocardium (8.6+/-2.9 vs 6.0+/-1.8 and 9.3+/-3.1 vs 6.2+/-2.1 cm x s(-1)). Using receiver operating characteristic curves the optimal cut-off value for viability assessment was an increase in the ejection phase velocity low-dose of 1+/-0.5 cm x s(-1), while 0+/-0.5 cm x s(-1)predicted non-viability. The sensitivity and specificity (95%CI) of pulsed-wave Doppler tissue sampling and dobutamine-stress echocardiography for the prediction of viability was respectively 87% (82-92) vs 75% (67-81) (P<0.05) and 52% (44-59) vs 51% (45-59) (P=ns). CONCLUSIONS: The sensitivity of pulsed-wave Doppler tissue sampling is superior to dobutamine-stress echocardiography for the assessment of myocardial viability.

Three-Dimensional Myocardial Perfusion Maps by Contrast Echocardiography (Article)

1997-07-01T00:00:00Z

We evaluated the clinical applicability of a system for three-dimensional (3-D) display of a perfusion map following myocardial contrast echocardiography (MCE). The system was used in 12 patients (9 males and 3 females, mean age 52 ± 10 years) undergoing interventional treatment of chronic total coronary occlusion. In each patient three standard apical views were acquired at baseline with sonicated IopamidolR injections into the left coronary artery (LCA) and into the right coronary artery (RCA). Following successful recanalization of the occluded artery MCE was repeated. The patients tolerated the procedure well. Acquisition of three standard apical views provided sufficient information for the reconstruction of 3-D perfusion maps containing the 16 standard left ventricular (LV) segments. Side-by-side display of the perfusion maps obtained following LCA and RCA echocontrast injections allowed us to classify the myocardial segments (192) into three groups: (1) those supplied by one major artery (124); (2) those supplied by collaterals from contralateral or both major arteries (58); and (3) segments supplied by none of the major arteries (10). Decreased opacification was observed in 50 segments of group 2. Following successful intervention we were able to visualize the redistribution of blood flow delivered to the LV myocardium by each major coronary artery in 3-D format. We conclude that this 3-D approach, which can easily be performed with currently available ultrasound equipment, allows an estimate of the contribution of each major coronary artery to LV perfusion before and after coronary angioplasty.

Quantitative assessment of myocardial blood flow by contrast two-dimensional echocardiography: initial clinical observations (Article)

1987-01-01T00:00:00Z

Myocardial contrast two-dimensional echocardiography (MC-2DE) is a new technique to study myocardial perfusion imaging. Whether quantitative analysis of MC-2DE has any clinical significance is not known. We studied 12 patients during cardiac catheterization and coronary arteriography by MC-2DE, using sonicated iopamidol (microbubble size 12 +/- 4 micron) as the echocontrast agent. Selective intracoronary injections of 4 cc were performed into the left and right coronary artery. Two-dimensional echocardiograms were made before, during, and after injection from the apical four-chamber view. The coronary artery stenosis was calculated by automated boundary detection from the digitized cine arteriograms and expressed as percentage area stenosis (%S); also the absolute minimal luminal area (L) was calculated. From the MC-2DE video images, end-diastolic frames were chosen for digitization and videointensity measured from a region of interest at basal or midseptal level. This analysis reveals a curve of echo intensity versus time. From these curves, total curve area (A), curve duration (T), and time from peak intensity to 50% intensity decay (T50) were measured. Multiple regression analysis reveals the best correlation between %S and A (A = 52.48. e0.02%S; P less than .0001; r = 0.89). Correlations between %S, L, and T and T50, respectively, were less. Thus MC-2DE quantitative analysis shows a good agreement with anatomical size of coronary artery stenosis. These findings might have important clinical implications for future follow-up of various therapeutic procedures such as transluminal angioplasty thrombolysis.

Extent of hypertrophy in hypertrophic cardiomyopathy: two-dimensional echocardiographic and angiographic correlation (Article)

1983-01-01T00:00:00Z

Since the first anatomical and functional descriptions of hypertrophic cardiomyopathy (HCM) there have been convincing attempts at better understanding and definition of the controversial aspects of this complex disease.