Cate, F.J. ten

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.

Mortality risk of untreated myosin-binding protein crelated hypertrophic cardiomyopathy: Insight into the natural history (Article)

2011-11-29T00:00:00Z

Objectives: The goal of this study was to assess the mortality of hypertrophic cardiomyopathy (HCM), partly in times when the disease was not elucidated and patients were untreated. Background: HCM is feared for the risk of sudden cardiac death (SCD). Insight in the natural history of the disorder is needed to design proper screening strategies for families with HCM. Methods: In 6 large, 200-year multigenerational pedigrees (identified by using genealogical searches) and in 140 small (contemporary) pedigrees (first-degree relatives of the proband) with HCM caused by a truncating mutation in the myosin-binding protein C gene (n = 1,118), we determined all-cause mortality using the family tree mortality ratio method. The studys main outcome measure was the standardized mortality ratio (SMR). Results: In the large pedigrees, overall mortality was not increased (SMR 0.86 [95% confidence interval (CI): 0.72 to 1.03]), but significant excess mortality occurred between 10 and 19 years (SMR 2.7 [95% CI: 1.2 to 5.2]). In the small families, the SMR was increased (SMR 3.2 [95% CI: 2.3 to 4.3]) and excess mortality was observed between 10 and 39 years (SMR 3.2 [95% CI: 2.3 to 4.3]) and 50 and 59 years (SMR 1.9 [95% CI: 1.4 to 2.5]). Conclusions: We identified specific age categories with increased mortality risks in HCM families. The small, referred pedigrees had higher mortality risks than the large 200-year multigenerational pedigrees. Our findings support the strategy of starting cardiological and genetic screening in the first-degree relatives of a proband from 10 years onward and including persons in the screening at least until the age of 60 years. Screening of more distant relatives is probably most efficient between 10 and 19 years.

Right ventricular energetics in patients with hypertrophic cardiomyopathy and the effect of alcohol septal ablation (Article)

2011-10-01T00:00:00Z

Background: Diastolic dysfunction in hypertrophic cardiomyopathy (HCM) is accompanied by augmented left ventricular (LV) end-diastolic pressure, above all in the presence of LV outflow tract (LVOT) obstruction. Increased back-pressure may augment right ventricular (RV) afterload and induce an oxidative metabolic imbalance between the 2 ventricles. The aim was to study right-to-left ventricular oxidative metabolism in HCM and the effects of alcohol septal ablation (ASA). Methods and Results: Twenty-one HCM patients were enrolled. Eleven healthy subjects served as a control group. Subjects underwent 2-dimensional echocardiography to assess LVOT gradient, left atrial size, and diastolic function. [11C]Acetate positron-emission tomography (PET) was performed to determine RVk2and LVk2, as a noninvasive index of oxidative metabolism. Seven HCM patients with LVOT obstruction, scheduled to undergo ASA, were also studied 6 months after the procedure. RVk2was higher in HCM patients than i control subjects (0.081 ± 0.021 min-1vs. 0.061 ± 0.017 min-1; P =.05), whereas LVk2was similar between groups. Consequently, RVk2/LVk2was increased in the patients (0.85 ± 0.19 vs 0.59 ± 0.13; P =.004). In patients with obstructive HCM, ASA reduced RVk2(0.085 ± 0.021 min-1to 0.072 ± 0.022 min-1; P =.001). Inasmuch as LVk2remained unaffected by the procedure, RVk2/LVk2was decreased after ASA (0.66 ± 0.18; P =.03). The absolute change in LVOT gradient was related to the absolute change in RVk2(r = 0.77; P =.044). Conclusions: In HCM patients, RV oxygen consumption is increased in relation to the LV. ASA reduces RV oxygen consumption in HCM patients with LVOT obstruction, suggesting that increased LV loading conditions and diastolic dysfunction play a predominant role in augmenting RV workload in these patients.

Effects of alcohol septal ablation on coronary microvascular function and myocardial energetics in hypertrophic obstructive cardiomyopathy (Article)

2011-07-01T00:00:00Z

This study investigated the effects of alcohol septal ablation (ASA) on microcirculatory function and myocardial energetics in patients with hypertrophic cardiomyopathy (HCM) and left ventricular outflow tract (LVOT) obstruction. In 15 HCM patients who underwent ASA, echocardiography was performed before and 6 mo after the procedure to assess the LVOT gradient (LVOTG). Additionally, [15O]water PET was performed to obtain resting myocardial blood flow (MBF) and coronary vasodilator reserve (CVR). Changes in LV mass (LVM) and volumes were assessed by cardiovascular magnetic resonance imaging. Myocardial oxygen consumption (MV ̇ O2) was evaluated by [11C]acetate PET in a subset of seven patients to calculate myocardial external efficiency (MEE). After ASA, peak LVOTG decreased from 41 ± 32 to 23 ± 19 mmHg (P = 0.04), as well as LVM (215 ± 74 to 169 ± 63 g; P < 0.001). MBF remained unchanged (0.94 ± 0.23 to 0.98 ± 0.15 ml·min-1·g-1; P = 0.45), whereas CVR increased (2.55 ± 1.23 to 3.05 ± 1.24; P = 0.05). Preoperatively, the endo-toepicardial MBF ratio was lower during hyperemia compared with rest (0.80 ± 0.18 vs. 1.18 ± 0.15; P < 0.001). After ASA, the endo-toepicardial hyperemic (h)MBF ratio increased to 1.03 ± 0.26 (P = 0.02). ΔCVR was correlated to ΔLVOTG (r=-0.82; P < 0.001) and ΔLVM (r=-0.54; P = 0.04). MEE increased from 15 ± 6 to 20 ± 9% (P = 0.04). Coronary microvascular dysfunction in obstructive HCM is at least in part reversible by relief of LVOT obstruction. After ASA, hMBF and CVR increased predominantly in the subendocardium. The improvement in CVR was closely correlated to the absolute reduction in peak LVOTG, suggesting a pronounced effect of LV loading conditions on microvascular function of the subendocardium. Furthermore, ASA has favorable effects on myocardial energetics.

Relation of coronary microvascular dysfunction in hypertrophic cardiomyopathy to contractile dysfunction independent from myocardial injury (Article)

2011-05-15T00:00:00Z

We studied the spatial relations among hyperemic myocardial blood flow (hMBF), contractile function, and morphologic tissue alterations in 19 patients with hypertrophic cardiomyopathy (HC). All patients were studied with oxygen-15 water positron emission tomography during rest and adenosine administration to assess myocardial perfusion. Cardiovascular magnetic resonance was performed to derive delayed contrast-enhanced images and to calculate contractile function (Ecc) with tissue tagging. Eleven healthy subjects underwent similar positron emission tomographic and cardiovascular magnetic resonance scanning protocols and served as a control group. In the HC group, hMBF averaged 2.46 ± 0.91 ml/min/g and mean Eccwas -14.7 ± 3.4%, which were decreased compared to the control group (3.97 ± 1.48 ml/min/g and -17.7 ± 3.2%, respectively, p <0.001 for the 2 comparisons). Delayed contrast enhancement (DCE) was present only in patients with HC, averaging 6.2 ± 10.3% of left ventricular mass. In the HC group, Eccand DCE in the septum (-13.7 ± 3.6% and 10.2 ± 13.6%) significantly differed from the lateral wall (-16.0 ± 2.8% and 2.4 ± 5.9%, p <0.001 for the 2 comparisons). In general, hMBF and Eccwere decreased in segments displaying DCE compared to nonenhanced segments (p <0.001 for the comparisons). In the HC group, univariate analysis revealed relations of hMBF to Ecc(r = -0.45, p <0.001) and DCE (r = -0.31, p <0.001). Multivariate analysis revealed that Eccwas independently related to hMBF (beta -0.37, p <0.001) and DCE (beta 0.28, p <0.001). In conclusion, in HC hMBF is impaired and related to contractile function independent from presence of DCE. When present, DCE reflected a progressed disease state as characterized by an increased perfusion deficit and contractile dysfunction.

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.

Paradoxical effects of interatrial conduction delay in a hypertrophic cardiomyopathy patient in the long-term: Time is a great healer (Article)

2011-05-01T00:00:00Z

Paradoxical Effects of Interatrial Conduction Delay. We present a unique case where early proarrhythmic and late antiarrhythmic characteristics of interatrial conduction delay were observed during the long-term progression of HCM. Occurrence of AT constantly increased as the interatrial conduction delay became more prominent, while the P-wave width in sinus rhythm and the AT cycle length both showed an instantaneous increase in parallel. As the interatrial delay reached a critical point, the right and left atrial P-wave became virtually separated, as demonstrated by the findings of ECGs and echocardiography. This phenomenon resulted in the complete cessation of tachycardias. (J Cardiovasc Electrophysiol, Vol. 22, pp. 587-589 May 2011)

Close connection between improvement in left ventricular function by cardiac resynchronization therapy and the incidence of arrhythmias in cardiac resynchronization therapy-defibrillator patients (Article)

2010-12-01T00:00:00Z

Aims The aim of this study was to determine the relationship between improved ejection fraction (EF) and occurrence of arrhythmias in patients with cardiac resynchronization therapy devices with defibrillator function (CRT-D). The hypothesis was that patients who experienced a marked improvement in EF also had fewer appropriate defibrillator interventions. Methods and results We analysed data of 270 patients from2 prospective registries with follow-up of ≥12 months and echocardiography performed ≥8 months after CRT-D implantation. The discriminator was whether left ventricular ejection fraction (LVEF) improved to >35 [cut-off for primary prevention implantable cardioverter-defibrillator (ICD) implantation]. Mean age was 61 ± 11 years, LVEF 22 ± 5, and follow-up 40 ± 22 months. Ischaemic cardiomyopathy was present in 48, and secondary prevention indication was present in 25. Implantable cardioverter-defibrillator interventions were delivered to 35 of patients. Echocardiography (20 ± 15 months after implantation) showed an improvement in LVEF from 22 (SD 5.4) to 30 (SD 9.8). Improvement to >35 was seen in 21 of patients. Those who improved to >35 had fewer ICD interventions than those who did not (23 vs.38; P-value 0.03). Analysing only patients with a primary prevention indication and stratifying again in patients with and without improvement of LVEF to >35, the latter had highly significant more ICD-therapies (6 vs. 31; P-value 0.0008).Conclusion Patients with CRT-D for primary prevention, whose LVEF improved to >35 during mid-term follow-up, are at low risk of first ICD therapies beyond year 1. If similar findings are reported in other patient cohorts, this might impact on decision-making at the time of battery depletion.

Recovery of long-axis left ventricular function after aortic valve replacement in patients with severe aortic stenosis (Article)

2010-11-01T00:00:00Z

Background: Patients with aortic stenosis (AS) should undergo aortic valve replacement (AVR) before irreversible LV dysfunction has developed. Assessment of long-axis left ventricular (LV) function may assist in proper timing of AVR. Objectives: To assess serial changes in long-axis LV function before and after AVR in patients with severe AS and preserved LV ejection fraction. Methods: The study comprised 27 consecutive patients (mean age 64.9 ± 11.7 years, 15 males) with symptomatic severe AS, scheduled for AVR. Seventeen subjects without known cardiac disease, matched for age, gender, LV ejection fraction and cardiovascular risk factors, served as a control group. Long-axis LV function assessment was done with tissue Doppler imaging at 3 weeks, 6 months, and 12 months after AVR. Results: Mean aortic valve area in the AS group was 0.70 ± 0.24 cm2. Pre-AVR peak systolic mitral annular velocities were significantly lower compared to controls (6.7 ± 1.5 vs. 8.9 ± 2.0 cm/s, P < 0.05). Post-AVR peak systolic mitral annular velocities improved to 9.1 ± 2.9 at 3 weeks, 8.6 ± 2.7 at 6 months, and 8.1 ± 1.7 cm/s at 12 months (P < 0.05). Improvements were seen over the whole range of pre-AVR peak systolic mitral annular velocities. Patients with improved Sm after AVR (defined as ≥10% compared to baseline values) did not differ in baseline characteristics as compared to those who did not improve. Conclusions: In patients with severe AS and preserved LV ejection fraction, abnormal systolic mitral annular velocities improve after AVR, independent of the pre-AVR value.

Molecular imaging of inflammation and intraplaque vasa vasorum: A step forward to identification of vulnerable plaques? (Article)

2010-10-01T00:00:00Z

Current developments in cardiovascular biology and imaging enable the noninvasive molecular evaluation of atherosclerotic vascular disease. Intraplaque neovascularization sprouting from the adventitial vasa vasorum has been identified as an independent predictor of intraplaque hemorrhage and plaque rupture. These intraplaque vasa vasorum result from angiogenesis, most likely under influence of hypoxic and inflammatory stimuli. Several molecular imaging techniques are currently available. Most experience has been obtained with molecular imaging using positron emission tomography and single photon emission computed tomography. Recently, the development of targeted contrast agents has allowed molecular imaging with magnetic resonance imaging, ultrasound and computed tomography. The present review discusses the use of these molecular imaging techniques to identify inflammation and intraplaque vasa vasorum to identify vulnerable atherosclerotic plaques at risk of rupture and thrombosis. The available literature on molecular imaging techniques and molecular targets associated with inflammation and angiogenesis is discussed, and the clinical applications of molecular cardiovascular imaging and the use of molecular techniques for local drug delivery are addressed.

Cardiomyopathies: a revolution in molecular medicine and cardiac imaging (Article)

2010-09-30T00:00:00Z

Contrast-enhanced ultrasound for imaging vasa vasorum: Comparison with histopathology in a swine model of atherosclerosis (Article)

2010-09-01T00:00:00Z

AimTo evaluate the agreement between contrast-enhanced ultrasound imaging and histopathology in an animal model of atherosclerosis.Methods and results: Atherosclerosis was studied in both femoral arteries of four Rapacz familial hypercholesterolaemia (RFH) swine. Contrast-enhanced ultrasound imaging of the eight femoral arteries was performed at baseline and at 5, 12, 26, and 43 weeks follow-up after percutaneous transluminal stimulation of atherosclerosis to assess the progression of intima-media thickness (IMT) and the density and extent of the vasa vasorum network. Contrast-enhanced ultrasound imaging allowed an early detection of atherosclerosis and showed a significant gradual progression of atherosclerosis over time. IMT increased from 0.22 ± 0.05 mm at baseline to 0.45 ± 0.06 mm (P < 0.001) at follow-up. The density of the vasa vasorum network increased during follow-up and was significantly higher in advanced than in early atherosclerosis. The findings with contrast-enhanced ultrasound were confirmed by histopathological specimens of the arterial wall.Conclusion: Contrast-enhanced ultrasound is effective for in vivo detection of vasa vasorum in atherosclerotic plaques in the RFH swine model. After stimulation of atherosclerosis, contrast-enhanced ultrasound demonstrated a significantly increased IMT and significantly increased density of the vasa vasorum network in the developing atherosclerotic plaque, which was validated by histology.

Contrast-enhanced ultrasound imaging of the vasa vasorum: From early atherosclerosis to the identification of unstable plaques (Article)

2010-07-01T00:00:00Z

Proliferation of the adventitial vasa vasorum (VV) is inherently linked with early atherosclerotic plaque development and vulnerability. Recently, direct visualization of arterial VV and intraplaque neovascularization has emerged as a new surrogate marker for the early detection of atherosclerotic disease. This clinical review focuses on contrast-enhanced ultrasound (CEUS) as a noninvasive application for identifying and quantifying carotid and coronary artery VV and intraplaque neovascularization. These novel approaches could potentially impact the clinician's ability to identify individuals with premature cardiovascular disease who are at high risk. Once clinically validated, the uses of CEUS may provide a method to noninvasively monitor therapeutic interventions. In the future, the therapeutic use of CEUS may include ultrasound-directed, site-specific therapies using microbubbles as vehicles for drug and gene delivery systems. The combined applications for diagnosis and therapy provide unique opportunities for clinicians to image and direct therapy for individuals with vulnerable lesions.

The importance of genetic counseling, DNA diagnostics, and cardiologic family screening in left ventricular noncompaction cardiomyopathy (Article)

2010-06-01T00:00:00Z

Background-Left ventricular (LV) noncompaction(LVNC) is a distinct cardiomyopathy featuring a thickened bilayered LV wall consisting of a thick endocardial layer with prominent intertrabecular recesses with a thin, compact epicardial layer. Similar to hypertrophic and dilated cardiomyopathy, LVNC is genetically heterogeneous and was recently associated with mutations in sarcomere genes. To contribute to the genetic classification for LVNC, a systematic cardiological family study was performed in a cohort of 58 consecutively diagnosed and molecularly screened patients with isolated LVNC (49 adults and 9 children). Methods and Results-Combined molecular testing and cardiological family screening revealed that 67% of LVNC is genetic. Cardiological screening with electrocardiography and echocardiography of 194 relatives from 50 unrelated LVNC probands revealed familial cardiomyopathy in 32 families (64%), including LVNC, hypertrophic cardiomyopathy, and dilated cardiomyopathy. Sixty-three percent of the relatives newly diagnosed with cardiomyopathy were asymptomatic. Of 17 asymptomatic relatives with a mutation, 9 had noncompaction cardiomyopathy. In 8 carriers, nonpenetrance was observed. This may explain that 44% (14 of 32) of familial disease remained undetected by ascertainment of family history before cardiological family screening. The molecular screening of 17 genes identified mutations in 11 genes in 41% (23 of 56) tested probands, 35% (17 of 48) adults and 6 of 8 children. In 18 families, single mutations were transmitted in an autosomal dominant mode. Two adults and 2 children were compound or double heterozygous for 2 different mutations. One adult proband had 3 mutations. In 50% (16 of 32) of familial LVNC, the genetic defect remained inconclusive. Conclusion-LVNC is predominantly a genetic cardiomyopathy with variable presentation ranging from asymptomatic to severe. Accordingly, the diagnosis of LVNC requires genetic counseling, DNA diagnostics, and cardiological family screening.

Long-term outcome of alcohol septal ablation in patients with obstructive hypertrophic cardiomyopathy: A word of caution (Article)

2010-05-01T00:00:00Z

Background: The impact of alcohol septal ablation (ASA)-induced scar is not known. This study sought to examine the long-term outcome of ASA among patients with obstructive hypertrophic cardiomyopathy. Methods and Results: Ninety-one consecutive patients (aged 54±15 years) with obstructive hypertrophic cardiomyopathy underwent ASA. Primary study end point was a composite of cardiac death and aborted sudden cardiac death including appropriate cardioverter-defibrillator discharges for fast ventricular tachycardia/ ventricular fibrillation. Secondary end points were noncardiac death and other nonfatal complications. Outcomes of ASA patients were compared with 40 patients with hypertrophic cardiomyopathy who underwent septal myectomy. During 5.4±2.5 years, primary and/or secondary end points were seen in 35 (38%) ASA patients of whom 19 (21%) patients met the primary end point. The 1-, 5-, and 8-year survival-free from the primary end point was 96%, 86%, and 67%, respectively in ASA patients versus 100%, 96%, and 96%, respectively in myectomy patients during 6.6±2.7 years (log-rank, P=0.01). ASA patients had a ≈5-fold increase in the estimated annual primary end point rate (4.4% versus 0.9%) compared with myectomy patients. In a multivariable model including a propensity score, ASA was an independent predictor of the primary end point (unadjusted hazard ratio, 5.2; 95% CI, 1.2 to 22.1; P=0.02 and propensity score-adjusted hazard ratio, 6.1; 95% CI, 1.4 to 27.1; P=0.02). Conclusions: This study shows that ASA has potentially unwanted long-term effects. This poses special precaution, given the fact that ASA is practiced worldwide at increasing rate. We recommend myectomy as the preferred intervention in patients with obstructive hypertrophic cardiomyopathy.

Incidence, pathophysiology, and treatment of complications during dobutamine-atropine stress echocardiography (Article)

2010-04-01T00:00:00Z

Potential of [11C]acetate for measuring myocardial blood flow: Studies in normal subjects and patients with hypertrophic cardiomyopathy (Article)

2010-04-01T00:00:00Z

Background: Measuring the rate of clearance of carbon-11 labelled acetate from myocardium using positron emission tomography (PET) is an accepted technique for noninvasively assessing myocardial oxygen consumption. Initial myocardial uptake of [11C]acetate, however, is related to myocardial blood flow (MBF) and several tracer kinetic models for quantifying MBF using [11C]acetate have been proposed. The objective of this study was to assess these models. Methods: Eighteen healthy subjects and 18 patients with hypertrophic cardiomyopathy (HCM) were studied under baseline conditions with [11C]acetate and [15O]water. Four previously reported methods, including single- and multi-tissue compartment models, were used to calculate MBF from the measured [11C]acetate rate of influx K1and the (previously) reported relationship between K1and MBF. These MBF values were then compared with those derived from corresponding [15O]water studies. Results: For all models, correlations between [11C]acetate and [15O]water-derived MBF ranged from .67 to .86 (all P < .005) in the control group and from .73 to .85 (all P < .001) in the HCM group. Two out of four models systematically underestimated perfusion with [11C]acetate, whilst the third model resulted in an overestimation. The fourth model, based on a simple single tissue compartment model with spillover, partial volume and recirculating metabolite corrections, resulted in a regression equation with a slope of near unity and an Y-intercept of almost zero (controls, K1= .74[MBF] 1 .09, r = .86, SEE = .13, P < .001 and HCM, K1= .89[MBF] 1 .03, r = .85, SEE = .12, P < .001). Conclusion: [11C]acetate enables quantification of MBF in fairly good agreement with actual MBF in both healthy individuals and patients with HCM. A single tissue compartment model with standardized correction for recirculating metabolites and with corrections for partial volume and spillover provided the best results. Copyright

Determinants of myocardial energetics and efficiency in symptomatic hypertrophic cardiomyopathy (Article)

2010-04-01T00:00:00Z

Purpose: Next to hypertrophy, hypertrophic cardiomyopathy (HCM) is characterized by alterations in myocardial energetics. A small number of studies have shown that myocardial external efficiency (MEE), defined by external work (EW) in relation to myocardial oxidative metabolism (MVO2), is reduced. The present study was conducted to identify determinants of MEE in patients with HCM by use of dynamic positron emission tomography (PET) and cardiovascular magnetic resonance imaging (CMR). Methods: Twenty patients with HCM (12 men, mean age: 55.2 ± 13.9 years) and 11 healthy controls (7 men, mean age: 48.1 ± 10 years) were studied with [11C]acetate PET to assess MVO2. CMR was performed to determine left ventricular (LV) volumes and mass (LVM). Univariate and multivariate analyses were employed to determine independent predictors of myocardial efficiency. Results: Between study groups, MVO2(controls: 0.12 ± 0.04 ml•min-1•g-1, HCM: 0.13 ± 0.05 ml•min-1•g-1, p = 0.64) and EW (controls: 9,139 ± 2,484 mmHg•ml, HCM: 9,368 ± 2,907 mmHg•ml, p = 0.83) were comparable, whereas LVM was significantly higher (controls: 99 ± 21 g, HCM: 200 ± 76 g, p < 0.001) and MEE was decreased in HCM patients (controls: 35 ± 8%, HCM: 21 ± 10%, p < 0.001). MEE was related to stroke volume (SV), LV outflow tract gradient, NH2-terminal pro-brain natriuretic peptide (NT-proBNP) and serum free fatty acid levels (all p < 0.05). Multivariate analysis revealed that SV ( = 0.74, p < 0.001) and LVM ( = -0.43, p = 0.013) were independently related to MEE. Conclusion: HCM is characterized by unaltered MVO2, impaired EW generation per gram of myocardial tissue and subsequent deteriorated myocardial efficiency. Mechanical external efficiency could independently be predicted by SV and LVM.

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.

Validation of a New Score for the Assessment of Mitral Stenosis Using Real-Time Three-Dimensional Echocardiography (Article)

2010-01-01T00:00:00Z

Background: The aim of this study was to validate a new real-time three-dimensional echocardiography (RT3DE) score for evaluating patients with mitral stenosis (MS). Methods: A two-staged study was conducted. In the first stage, the feasibility of a new RT3DE score was assessed in 17 patients with MS. The second stage was planned to validate the RT3DE score in 74 consecutive patients undergoing percutaneous mitral valvuloplasty. The new RT3DE score was constructed by dividing each mitral valve (MV) leaflet into 3 scallops and was composed of 31 points (indicating increasing abnormality), including 6 points for thickness, 6 for mobility, 10 for calcification, and 9 for subvalvular apparatus involvement. The total RT3DE score was calculated and defined as mild (<8), moderate (8-13), or severe (≥14). MV morphology was assessed using Wilkins's score and compared with the new RT3DE score. Results: In the first stage, the RT3DE score was feasible and easily applied to all patients, with good interobserver and intraobserver agreement. In the second stage, RT3DE improved MV morphologic assessment, particularly for the detection of calcification and commissural splitting. Both scores were correlated for assessment of thickness and calcification (r = 0.63, P < .0001, and r = 0.44, P < .0001, respectively). Predictors of optimal percutaneous mitral valvuloplasty success by Wilkins's score were leaflet calcification and subvalvular apparatus involvement, and those by RT3DE score were leaflet mobility and subvalvular apparatus involvement. The incidence and severity of mitral regurgitation were associated with high-calcification RT3DE score. Conclusion: The new RT3DE score is feasible and highly reproducible for the assessment of MV morphology in patients with MS. It can provide incremental prognostic information in addition to Wilkins's score.

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.

Prognostic Significance of QRS Duration in Patients With Suspected Coronary Artery Disease Referred for Noninvasive Evaluation of Myocardial Ischemia (Article)

2009-12-01T00:00:00Z

The purpose of this study was to evaluate the prognostic significance of QRS duration in patients with suspected coronary artery disease (CAD) referred for noninvasive evaluation of myocardial ischemia by dobutamine stress echocardiography. QRS duration is a prognostic marker in patients with previous myocardial infarction and/or heart failure. The relation between QRS duration and outcome of patients without known heart disease has not been evaluated. A total of 1,227 patients (707 men, mean age 61 ± 14 years) with suspected CAD underwent dobutamine stress echocardiography for evaluation of myocardial ischemia. Patients were followed to determine predictors of cardiac events and to assess the incremental significance of QRS duration compared to clinical and dobutamine stress echocardiographic data. During a mean follow-up of 4.2 ± 2.4 years, 280 patients (23%) died (129 cardiac deaths), and 60 (5%) had a nonfatal infarction. Annualized cardiac death rates were 2.0% in patients with QRS duration <120 ms and 4.4% in patients with QRS duration ≥120 ms, respectively (p <0.0001). Annualized event rates for cardiac death/nonfatal infarction were 2.8% in patients with QRS duration <120 ms and 4.8% in patients with QRS duration ≥120 ms (p = 0.0001). Multivariate models identified age, male gender, smoking, QRS duration ≥120 ms, and an abnormal dobutamine stress echocardiogram as independent predictors of cardiac death and the combined end point cardiac death/nonfatal infarction. In conclusion, QRS duration is an independent predictor of cardiac death and cardiac death/nonfatal infarction in patients with suspected CAD. This risk is persistent after adjustment for clinical variables, left ventricular function, and myocardial ischemia.

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.

Disease penetrance and risk stratification for sudden cardiac death in asymptomatic hypertrophic cardiomyopathy mutation carriers (Article)

2009-11-01T00:00:00Z

AimsTo investigate the outcome of cardiac evaluation and the risk stratification for sudden cardiac death (SCD) in asymptomatic hypertrophic cardiomyopathy (HCM) mutation carriers.Methods and resultsSeventy-six HCM mutation carriers from 32 families identified by predictive DNA testing underwent cardiac evaluation including history, examination, electrocardiography, Doppler echocardiography, exercise testing, and 24 h Holter monitoring. The published diagnostic criteria for HCM in adult members of affected families were used to diagnose HCM. Thirty-three (43) men and 43 (57) women with a mean age of 42 years (range 16-79) were examined; in 31 (41) HCM was diagnosed. Disease penetrance was age related and men were more often affected than women (P = 0.04). Myosin Binding Protein C (MYBPC3) mutation carriers were affected at higher age than Myosin Heavy Chain (MYH7) mutation carriers (P = 0.01). Risk factors for SCD were present in affected and unaffected carriers.ConclusionHypertrophic cardiomyopathy was diagnosed in 41 of carriers. Disease penetrance was age dependent, warranting repeated cardiologic evaluation. The MYBPC3 mutation carriers were affected at higher age than MYH7 mutation carriers. Risk factors for SCD were present in carriers with and without HCM. Follow-up studies are necessary to evaluate the effectiveness of risk stratification for SCD in this population.

Factors Affecting Sensitivity and Specificity of Diagnostic Testing: Dobutamine Stress Echocardiography (Article)

2009-11-01T00:00:00Z

Background: Clinical characteristics of patients, angiographic referral bias, and several technical factors may all affect the reported diagnostic accuracy of tests. The aim of this study was to assess their influence on the diagnostic accuracy of dobutamine stress echocardiography (DSE). Methods: The medical literature from 1991 to 2006 was searched for diagnostic studies using DSE and meta-analysis was applied to the 62 studies thus retrieved, including 6881 patients. These studies were analyzed for patient characteristics, angiographic referral bias, and several technical factors. Results: The sensitivity of DSE was significantly related to the inclusion of patients with prior myocardial infarctions (0.834 vs 0.740, P < .01) and defining the results of DSE as already positive in case of resting wall motion abnormalities rather than obligatory myocardial ischemia (0.786 vs 0.864, P < .01). Specificity tended to be lower when patients with resting wall motion abnormalities were included in a study (0.812 vs 0.877, P < .10). The presence of referral bias adversely affected the specificity of DSE (0.771 vs 0.842, P < .01). Conclusion: This analysis suggests that the reported sensitivity of DSE is likely higher and the specificity lower than expected in routine clinical practice because of the inappropriate inclusion of patients with prior myocardial infarctions, the definition of positive results on DSE, and the negative influence of referral bias. However, in the patient subset that will be sent to coronary angiography, the opposite results can be expected.

A microcosting study of diagnostic tests for the detection of coronary artery disease in the Netherlands (Article)

2009-10-01T00:00:00Z

Objective: The primary aim of the present study was to calculate the actual costs of four diagnostic tests for the detection of coronary artery disease in the Netherlands using a microcosting methodology. As a secondary objective, the cost effectiveness of eight diagnostic strategies was examined, using microcosting and reimbursement fees subsequently as the cost estimate. Design: A multicenter, retrospective cost analysis from a hospital perspective. Setting: The study was conducted in three general hospitals in the Netherlands for 2006. Interventions: Exercise electrocardiography (exECG), stress echocardiography (sECHO), single-photon emission computed tomography (SPECT) and coronary angiography (CA). Results: The actual costs of exECG, sECHO, SPECT and CA were €33, 216, 614 and 1300 respectively. For all diagnostic tests, labour and indirect cost components (overheads and capital) together accounted for over 75% of the total costs. Consumables played a relatively important role in SPECT (14%). Hotel and nutrition were only applicable to SPECT and CA. Diagnostic services were solely performed for CA, but their costs were negligible (2%). Using microcosting estimates, exECG-sECHO-SPECT-CA was the most and CA the least cost effective strategy (€397 and 1302 per accurately diagnosed patient). Using reimbursement fees, exECG-sECHO-CA was most and SPECT-CA least cost effective (€147 and 567 per accurately diagnosed patient). Conclusions: The use of microcosting estimates instead of reimbursement fees led to different conclusions regarding the relative cost effectiveness of alternative strategies.

The ischemic etiology of heart failure in diabetics limits reverse left ventricular remodeling after cardiac resynchronization therapy (Article)

2009-09-01T00:00:00Z

Aim of the Study: The aim of this study was to evaluate reverse volumetric left ventricular (LV) remodeling after cardiac resynchronization therapy (CRT) in patients with heart failure (HF) with vs. without diabetes mellitus (DM). Methods: The study comprised 130 consecutive patients with HF (mean age, 61±12 years) who underwent CRT. Thirty patients (23%) had DM [mean glycated haemoglobin (HbA1c), 7.2±3.4%; 13 (43%) on insulin therapy]. Echocardiography, including tissue Doppler measurements, was performed before CRT and between 3 and 6 months after CRT. Echocardiographic response was defined as a >15% reduction in LV end-systolic volume (ESV). Results: Patients with DM had more often hypertension (60% vs. 29%, P<.05) and ischemic HF etiology (87% vs. 51%, P<.05), but similar pre-CRT echocardiographic findings. After CRT, patients with DM had equal reductions in QRS duration and lateral-to-septal mechanical delay, but less improvement in LV ESV, mitral annular tissue velocity, the myocardial performance (or Tei) index and the E/E′ ratio (ratio of early transmitral peak filling velocity to early mitral annular peak diastolic velocity, an indicator of LV filling pressure). Patients without reverse volumetric LV remodeling had more often DM [hazard ratio (HR), 1.897; P=.042] and an ischemic HF etiology (HR, 2.308; P=.006). An ischemic HF etiology (HR, 2.119; P=.018) was the only independent predictor of poor reverse volumetric LV remodeling. Conclusion: Ischemic etiology of HF is an independent predictor of poor echocardiographic response to CRT. Patients with DM and HF have a relatively poor echocardiographic response to CRT most probably due to a high incidence of ischemic etiology of HF.

Improved aortic distensibility after aortic homograft root replacement at long-term follow-up (Article)

2009-08-14T00:00:00Z

Background: The ideal substitute for a diseased aortic valve remains unclear. Usually, the aortic full root replacement (FRR) technique is used, in which the native aortic root is removed and entirely replaced with the homograft aortic root, the coronary arteries being reimplanted into the homograft. The aim of the present study was to examine alterations in aortic size and stiffness in patients after FRR. Methods and patients: The study comprised 13 patients (mean age 46 ± 15 years, 10 males) who underwent FRR because of acute aortic regurgitation due to endocarditis in 6 patients (46%) and aortic valve stenosis with or without regurgitation in 7 patients (54%). These patients underwent transthoracic two-dimensional echocardiography before FRR, before discharge (9 ± 8 days post-FRR), and 6 months and 24 months after FRR. Systolic and diastolic ascending aortic diameters were recorded in M-mode at the middle of the ascending aorta, 3 to 4 cm above the aortic valve from a parasternal long-axis view. An aortic stiffness index (β) was calculated. The results were compared to 13 age-, gender- and risk factor-matched controls. Results: The aortic stiffness index first non-significantly deteriorated from 12.7 ± 8.1 to 16.4 ± 9.1 immediately after FRR. Subsequently, an improvement to 14.2 ± 7.1 (after 6 months) and 7.1 ± 4.8 (after 24 months, P < 0.05) was seen. Conclusions: FRR is associated with a transient immediate post-FRR deterioration followed by a progressive improvement in aortic distensibility.

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.

Three-dimensional transesophageal echocardiography: Diagnosing the extent of pericarditis constrictiva and intraoperative surgical support (Article)

2009-05-01T00:00:00Z

The traditional two-dimensional transthoracic echocardiography (2DTTE) has limitations in demonstrating the extent of pericardial thickening in constrictive pericarditis (CP) because of poor transmission of ultrasound through the thickened anterior pericardial structures. We describe a case of CP, of unknown etiology, in which transesophageal 3DTEE equalled the accuracy of cardiac magnetic resonance in demonstrating the extent of pericardial thickening in CP.

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.

Cardiac myosin-binding protein C mutations and hypertrophic ardiomyopathy haploinsufficiency, deranged phosphorylation, and cardiomyocyte dysfunction (Article)

2009-03-24T00:00:00Z

Mutations in the MYBPC3 gene, encoding cardiac myosin-binding protein C (cMyBP-C), are a frequent cause of familial hypertrophic cardiomyopathy. In the present study, we investigated whether protein composition and function of the sarcomere are altered in a homogeneous familial hypertrophic cardiomyopathy patient group with frameshift mutations in MYBPC3 (MYBPC3mut).Methods and Results- Comparisons were made between cardiac samples from MYBPC3 mutant carriers (c.2373dupG, n=7; c.2864-2865delCT, n=4) and nonfailing donors (n= 13). Western blots with the use of antibodies directed against cMyBP-C did not reveal truncated cMyBP-C in MYBPC3mut. Protein expression of cMyBP-C was significantly reduced in MYBPC3mutby 33 ±5%. Cardiac MyBP-C phosphorylation in MYBPC3mutsamples was similar to the values in donor samples, whereas the phosphorylation status of cardiac troponin I was reduced by 84 ±5%, indicating divergent phosphorylation of the 2 main contractile target proteins of the β-adrenergic pathway. Force measurements in mechanically isolated Triton-permeabilized cardiomyocytes demonstrated a decrease in maximal force per cross- sectional area of the myocytes in MYBPC3mut(20.2±2.7 kN/m2) compared with donor (34.5± 1.1 kN/m2). Moreover, Ca2+sensitivity was higher in MYBPC3mut(pCa50=5.62±0.04) than in donor (pCa50=5.54±0.02), consistent with reduced cardiac troponin I phosphorylation. Treatment with exogenous protein kinase A, to mimic β-adrenergic stimulation, did not correct reduced maximal force but abolished the initial difference in Ca sensitivity between MYBPC3mut(pCa50=5.46±0.03) and donor (pCa50=5.48±0. 02).Conclusions- Frameshift MYBPC3 mutations cause haploinsufficiency, deranged phosphorylation of contractile proteins, and reduced maximal force-generating capacity of cardiomyocytes. The enhanced Ca2+sensitivity in MYBPC3mutis due to hypophosphorylation of troponin I secondary to mutation-induced dysfunction.

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.

Diagnosis of biventricular non-compaction cardiomyopathy by real-time three-dimensional echocardiography (Article)

2009-03-01T00:00:00Z

Non-compaction of the ventricular myocardium is a recently recognized rare disorder of the endomyocardial morphogenesis. The disease can be characterized by systolic and diastolic heart failure, ventricular arrhythmias and systemic embolization. The present case suggests the clinical role of real-time three-dimensional echocardiography in the spatial evaluation of both ventricles in suspected biventricular non-compaction cardiomyopathy.

Impact of alcohol septal ablation on left anterior descending coronary artery blood flow in hypertrophic obstructive cardiomyopathy (Article)

2009-02-24T00:00:00Z

Objectives: The aim of this study was to evaluate the effects of alcohol septal ablation (ASA) on coronary blood flow in symptomatic hypertrophic obstructive cardiomyopathy (HOCM) using cardiac MR (CMR) coronary flow measurements. Background: CMR flow mapping enables quantification of coronary blood flow in a noninvasive way. Both left ventricular outflow tract (LVOT) gradient reduction and myocardial scarring after ASA are expected to influence left anterior descending (LAD) coronary blood flow. Methods: Cine, contrast-enhanced (CE) imaging and breath-hold CMR phase contrast velocity mapping were performed at baseline and 1 and 6 months after ASA in seven patients. Changes of coronary blood flow were related to left ventricular (LV) mass reduction, enzyme release, volume of ethanol administered, LVOT gradient reduction, and LV rate pressure product (LVRPP). Results: A significant mass reduction was observed bothin the target septal myocardium and in the total myocardium (both P < 0.01). Mean myocardial infarct size was 23 ± 12 g (range 7.3-41.6 g). LVRPP decreased from 13,268 ± 2,212 to 10,685 ± 3,918 at 1 month (P = 0.05) and 9,483 ± 2,496 mmHg beats/min at 6 months' follow-up (P < 0.01). LAD coronary blood flow decreased from 100 37 ml/min at baseline to 84 ± 54 ml/min (P = 0.09) at 1 month and 67 ± 33 ml/min at 6 months follow-up (P < 0.01). A significant correlation was found between the change in LVRPP and LAD coronary flow at 1 month follow-up (r = 0.83, P = 0.02). CE-infarct size tended to modulate the blood flow changes over time (P = 0.12); no correlation was observed between enzyme release, volume of ethanol or both septal and total mass reduction and coronary blood flow. Conclusion: The reductionin coronary blood flow is primarily associated with diminished LV loading conditions, whereas the induction of metabolically inactive myocardial scar tissue by ASA did not significantly influence the changes in coronary blood flow.

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.

Diastolic Abnormalities as the First Feature of Hypertrophic Cardiomyopathy in Dutch Myosin-Binding Protein C Founder Mutations (Article)

2009-01-01T00:00:00Z

Objectives: To test the hypothesis that carriers of Dutch founder mutations in cardiac myosin-binding protein C (MYBPC3), without left ventricular hypertrophy (LVH) or electrocardiographic abnormalities, have diastolic dysfunction on tissue Doppler imaging (TDI), which can be used for the screening of family members in the hypertrophic cardiomyopathy (HCM) population. Background: TDI is a more sensitive technique for the assessment of left ventricular contraction and relaxation abnormalities than is conventional echocardiography. Methods: Echocardiographic studies including TDI were performed in genotyped hypertrophic cardiomyopathy patients (genotype-positive, G+/LVH+; n = 27), mutation carriers without LVH (G+/LVH-; n = 27), and healthy controls (n = 55). The identified mutations in MYBPC3 in the G+/LVH+ subjects were c.2864_2865delCT (12 subjects), c.2373dupG (n = 8), and p. Arg943X (n = 7). In the G+/LVH- subjects, the following mutations were identified: c.2864_2865delCT (n = 11), c.2373dupG (n = 8), and p. Arg943X (n = 8). Results: Mean TDI-derived systolic and early and late diastolic mitral annular velocities were significantly lower in the G+/LVH+ subjects compared with the other groups. However, there was no difference between controls and G+/LVH- subjects. Mean TDI-derived late mitral annular diastolic velocities were significantly higher in the G+/LVH- subjects compared with controls and G+/LVH+ subjects. Using a cut-off value of mean ± 2 SD, an abnormal late mitral annular diastolic velocity was found in 14 (51%) of G+/LVH- patients. There was no difference among the 3 different mutations. Conclusions: In contrast to earlier reports, mean mitral annular systolic velocity and early mitral annular diastolic velocity velocities were not reduced in G+/LVH- subjects, and TDI velocities were not sufficiently sensitive for determination of the affected status of an individual subject. Our findings, however, support the theory that diastolic dysfunction is a primary component of pre-clinical HCM.

Intraoperative real time three-dimensional transesophageal echocardiographic measurement of hemodynamic, anatomic and functional changes after aortic valve replacement (Article)

2009-01-01T00:00:00Z

The traditional intraoperative two-dimensional transesophageal echocardiography (2DTEE) has limitations in measuring left ventricular ejection fraction (LVEF) because measurements rely on geometric assumptions. The availability of online software and real time three-dimensional transesophageal echocardiography (RT3D-TEE) makes intraoperative LVEF measurements fast and easy. This is the first report of intraoperative measurement of LVEF and aortic valve area (AVA) by RT3-DTEE in a patient who received transcatheter-based transapical aortic valve implantation.

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.

Prognostic role of aortic atherosclerosis and coronary flow reserve in patients with suspected coronary artery disease (Article)

2008-12-17T00:00:00Z

Background: The degree of aortic atherosclerosis (AA) and coronary flow reserve (CFR) can be evaluated simultaneously during the same transoesophageal echocardiographic (TEE) examination. The aim of the present study was to assess the relative prognostic value of simultaneously evaluated CFR and AA by TEE in patients with suspected or known coronary artery disease (CAD). Methods: The present study comprised 397 inhospital patients with chest pain. All patients underwent a transthoracic echocardiographic study to evaluate left ventricular function and a vasodilator TEE study to evaluate simultaneously CFR and the degree of AA. Results: Coronary angiography was performed in 292 patients (74%). Significant CAD was less frequent in patients with normal CFR and low-grade AA. During a mean follow-up of 41 ± 12 months, 23 patients suffered cardiovascular death (14 sudden cardiac death, 7 heart failure, 2 cardiovascular thrombosis). Univariate analysis yielded age, diabetes, AA grade and CFR as predictors of survival. Multivariate regression analysis showed that only CFR (hazard ratio (HR) 2.9, P < 0.02) and diabetes (HR 3.8, P < 0.01) were independent predictors of survival. Conclusions: It can be said that both CFR and AA grade are associated with poor survival but only CFR is an independent predictor.

Evaluation of left atrial systolic function in noncompaction cardiomyopathy by real-time three-dimensional echocardiography (Article)

2008-12-01T00:00:00Z

Background: Noncompaction cardiomyopathy (NCCM) is a rare disorder with persistance of the embryonic pattern of myoarchitecture. NCCM is characterized by loosened, spongy myocardium associated with a high incidence of systolic and diastolic left ventricular (LV) dysfunction and heart failure (HF). It is known that LV dysfunction contributes to elevated left atrial (LA) and pulmonary vascular pressures, however atrial function has not been examined in NCCM. The objective of the present study was to assess LA systolic function characterized by LA ejection force (LAEF) in NCCM patients using real-time three-dimensional echocardiography (RT3DE) and to compare to control subjects. Methods: The study comprised 17 patients with an established diagnosis of NCCM and their results were compared to 17 healthy age-matched controls with no evidence of cardiovascular disease. Forty-one percent of NCCM patients were in NYHA functional class II/III HF. Previously proposed echocardiographic diagnostic criteria for NCCM were used. All patients underwent conventional two-dimensional echocardiography and RT3DE. LAEF was measured based on MA annulus diameter (LAEF3D-MAD) and area (LAEF3D-MAA) using RT3DE. Results: The presence and severity of mitral regurgitation were more frequent in NCCM patients than in control subjects. LV diameters and mitral annulus were significantly increased in NCCM patients. Compared with control subjects, both LAEF3D-MAD(3.8 ± 2.2 vs 2.3 ± 1.0 kdyne P < 0.05 and LAEF3D-MAA(12.7 ± 7.6 vs 4.9 ± 2.1 kdyne, P < 0.01) were significantly increased in NCCM patients. Conclusions: LAEF as a characteristic of LA systolic function is increased in NCCM patients compared to normal individuals. These results can suggest compensating left atrial work against the dysfunctional LV in NCCM patients.

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.

Usefulness of intraoperative real-time 3D transesophageal echocardiography in cardiac surgery (Article)

2008-11-01T00:00:00Z

Background: Recent advances in three-dimensional (3D) echocardiography allow to obtain real-time 3D transesophageal (RT3DTEE) images intraoperatively. Methods: Preoperative transthoral echocardiography (TTE) revealed: hypertrophic ventricular septum (TTE:19.3 mm), systolic anterior motion (SAM) not causing obstruction and malcoaptation of the anterior mitral valve leaflet (AMVL), and posterior mitral valve leaflet (PMVL) with severe mitral regurgitation. Results: Intraoperative TEE with a x7-2t MATRIX-array transducer (Philips, Andover, MA, USA) with a transducer frequency of x7-2 t mHz, connected to a iE33 (Philips), shows us that the main mechanism and site of regurgitation was an AMVL cleft. We also measured a 24.3-mm thickness of the ventricular septum and analyzing the 3D full volume acquisition revealed that there was no SAM. Conclusion: Intraoperative RT3DTEE permitted comprehensive 3D viewing of the mitral valve revealing the mechanism of mitral valve regurgitation, SAM, and the exact width of the hypertrophic ventricular septum.

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.

Acute hemodynamic changes in percutaneous transluminal septal coil embolization for hypertrophic obstructive cardiomyopathy (Article)

2008-10-08T00:00:00Z

Background: A 48-year-old man with hypertrophic obstructive cardiomyopathy (HOCM) presented with palpitations, symptoms of medically refractory class II angina, and NYHA class II-III heart failure. Investigations: Physical examination revealed a grade 3 systolic murmur that increased to grade 4 with exercise. Echocardiography showed marked septal thickening (17 mm), a left ventricular outflow tract gradient (LVOTG) of 95 mmHg, and a 3+ systolic anterior motion of the mitral valve apparatus. No other pathology was noted with cardiac MRI or with coronary angiography. Diagnosis: Severe symptomatic HOCM. Management: Coil embolization of the first two septal vessels resulted in a limited septal infarct (creatine kinase-MB 36.6 μg/l; troponin T 0.43 μg/l) that corresponded to a mass of 8.1 g on gadolinium contrast cardiac MRI. The LVOTG decreased immediately from 78 mmHg to 35 mmHg. On pressure-volume loops, contractile isovolemic and systolic ejectional parameters decreased, while an improvement in diastolic left ventricular function was observed. Conclusion: Septal coil embolization acutely and effectively reduced the LVOTG in a patient with drug-refractory HOCM.

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

Acute effects of alcohol septal ablation on systolic and diastolic left ventricular function in patients with hypertrophic obstructive cardiomyopathy (Article)

2008-10-01T00:00:00Z

Objective: Hypertrophic obstructive cardiomyopathy (HOCM) often leads to heart failure, severe symptoms and death. Percutaneous transluminal septal myocardial ablation (PTSMA) by alcohol injection efficiently reduces left ventricular (LV) outflow tract pressure gradient and improves symptoms. We determined acute changes in haemodynamics and systolic and diastolic LV function after PTSMA. Methods: In 17 consecutive patients with symptomatic HOCM referred for PTSMA, the target vessel was determined by myocardial contrast transthoracic echo-cardiography. An over-the-wire balloon was inflated in the target vessel and multiple 0.5-ml alcohol injections were performed. LV systolic and diastolic function was - assessed by online pressure-volume loops obtained by conductance catheter at baseline and acutely after the procedure. Results: In all patients except two, a single septal branch was treated using a total of 2.0 (0.5) ml ethanol per patient. The rest and post-extrasystolic gradient were significantly decreased after PTSMA (79 (38) to 14 (16) mm Hg and 130 (50) to 34 (33) mm Hg, respectively, both p<0.001). Ejection fraction decreased (78% (9%) to 67% (13%), p<0.001). Cardiac output, heart rate and stroke work were unchanged, but systolic and diastolic volume increased. End-systolic and end-diastolic pressure significantly decreased (166 (27) to 129 (26) mm Hg, p<0.001 and 25 (6) to 21 (7) mm Hg, p = 0.049, respectively). Significant rightward shift (p<0.001) and decreased slope (p = 0.041) of the end-systolic pressure-volume relation indicated reduced contractility, whereas diastolic stiffness, -dP/dtMIN, and tau were significantly improved after the procedure. Conclusions: PTSMA acutely reduced systolic function but promptly improved diastolic function with maintained cardiac output and stroke work. Improved diastolic function and increased end-diastolic volume compensated for the systolic loss and resulted in maintained haemodynamics.

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.

Double orifice mitral valve by real-time three-dimensional echocardiography (Article)

2008-09-01T00:00:00Z

Double orifice mitral valve (DOMV) is a rare congenital malformation described as division of mitral orifice into two anatomically distinct orifices separated by an accessory bridge of fibrous tissue. In 85% of cases, both orifices are unequal in size. It is usually associated with other congenital defects such as atrioventricular septal defect and complex congenital heart disease. Most of cases could be diagnosed by two-dimensional echocardiography (2DE). The real-time three-dimensional echocardiography (RT3DE) helped in more detailed structure and function. Presented here RT3DE used for orientation of DOMV that allowed detailed and comprehensive assessment incremental to that obtained by 2DE.

Abnormal aortic elastic properties in adults with congenital valvular aortic stenosis (Article)

2008-08-29T00:00:00Z

Background: Abnormalities of the aortic root are common in patients with a bicuspid aortic valve. Our aim was to investigate the elastic properties of the aortic root in patients with congenital aortic valvular stenosis (AS) in comparison with age- and gender-matched controls, and to investigate the influence of stenosis severity and aortic size on aortic root elasticity. Methods: Thirty-two adults (mean age 30.4 ± 7.5 years, 22 men) with congenital AS without previous cardiovascular surgery were prospectively studied. Aortic root elasticity indices such as aortic stiffness index (ASI), aortic root distensibility (ARD), and aortic strain were calculated with the use of M-mode echocardiography. Results: ASI was significantly higher in patients compared to controls, 8.5 ± 8.4 versus 4.0 ± 1.4, respectively (P < 0.01). Other indices of aortic root elasticity were similar between patients and controls: ARD was 4.2 ± 3.6 versus 4.3 ± 1.9 × 10- 6cm2/dynes, respectively, and aortic strain was 12.4 ± 9.6 versus 13.5 ± 5.0%, respectively (P = NS for all). Correlations were found between aortic size and indices of aortic elasticity (i.e., aortic strain and ARD), denoting that an increased aortic dimension is associated with a stiffer aorta. Interestingly, no correlations were found between indices of severity of AS and aortic elasticity, suggesting that an abnormal aortic elasticity is independent of stenosis severity. Conclusions: Congenital AS results in abnormal aortic elastic properties, independent of stenosis severity. Furthermore, there seems to be a relationship between aortic dimensions and aortic stiffness.

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.

Echocardiographic evaluation and clinical implications of aortic stiffness and coronary flow reserve and their relationship (Article)

2008-07-01T00:00:00Z

The normal human aorta is not a stiff tube, but is characterized by elastic properties with a buffering Windkessel function. Aortic stiffening may cause an increase in aortic pulse pressure, left ventricular (LV) load, and ultimately left ventricular hypertrophy. This, together with the decreased diastolic transmyocardial pressure gradient, interacts with coronary flow and flow reserve. In recent studies, significant correlations between coronary flow reserve and aortic stiffness have been demonstrated in different patient populations. The aim of this review is to describe the current echocardiographic modalities to measure aortic stiffness and coronary flow reserve, and to overview knowledge about the relationship between aortic stiffness and coronary flow reserve.

Intraoperative real time three-dimensional transesophageal echocardiographic evaluation of right atrial tumor (Article)

2008-07-01T00:00:00Z

Right atrial myxomas are uncommon heart tumors that can simulate nonspecific symptoms, such as fever, paroxysmal palpitations, chronic anemia, weight loss, and may escape timely diagnosis until the development of severe complications due to embolism. We present a patient with a history of palpitations. In search for the source of palpitations, a 2D transthoracic echocardiography was performed, showing a right atrial mass. Real time three-dimensional transesophageal echocardiography (RT3DTEE) was performed intraoperative and demonstrated very accurate information about the size and the morphology of the tumor. This is the first case report of a right atrial myxoma visualized intraoperatively by RT3DTEE.

The mild form of mucopolysaccharidosis type I (Scheie syndrome) is associated with increased ascending aortic stiffness (Heart Vessels (2008) vol. 23 (108-111)) (Article)

2008-07-01T00:00:00Z

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.

Prognostic value of coronary flow reserve and aortic distensibility indices in patients with suspected coronary artery disease (Article)

2008-05-01T00:00:00Z

In recent studies it has been demonstrated that a reduced coronary flow reserve (CFR) is independently associated with a less benign long-term outcome. Aortic stiffness is one of the most important cardiovascular risk factors predicting cardiovascular morbidity and mortality. Vasodilator stress transesophageal echocardiography (TEE) is a suitable method to evaluate simultaneously CFR and elastic properties of the descending thoracic aorta. The aim of the present study was to assess the relative prognostic value of simultaneously measured CFR and aortic elastic properties by pulsed-wave Doppler TEE in patients with suspected or known coronary artery disease (CAD). The study comprised 157 in-hospital patients with chest pain. In all patients, stress TEE was used for the simultaneous evaluation of CFR and aortic distensibility indices [elastic modulus E (p) and Young's circumferential static elastic modulus E (s)]. During a mean follow-up of 48 ± 8 months, 13 patients suffered cardiovascular death. By univariate analysis older age, diabetes mellitus, increased left ventricular (LV) end-diastolic diameter, increased LV mass index, lower LV ejection fraction, and lower CFR were significant predictors of cardiovascular survival. Multivariate regression analysis showed that only CFR (hazard ratio [HR] 10.31, P = 0.04), age (HR 1.20, P = 0.001), and increased left ventricular (LV) end-diastolic diameter (HR 1.14, P = 0.02) were independent predictors of cardiovascular survival. Only in the small number of patients without CAD and abnormal CFR aortic distensibility seemed to provide complementary prognostic information over CFR. In the majority of patients aortic distensibility did not offer complementary prognostic information to CFR during vasodilator stress TEE testing.

Echocardiographic selection of candidates for cardiac resynchronization therapy: The lack of evidence! (Article)

2008-05-01T00:00:00Z

Effects of Percutaneous Transluminal Septal Myocardial Ablation for Obstructive Hypertrophic Cardiomyopathy on Systolic and Diastolic Left Ventricular Function Assessed by Pressure-Volume Loops (Article)

2008-04-15T00:00:00Z

The aim of the present study was to determine the long-term effects of percutaneous transluminal septal myocardial ablation (PTSMA) on systolic and diastolic left ventricular (LV) functions in patients with obstructive hypertrophic cardiomyopathy (HC). Ten consecutive patients with symptomatic HC despite optimal medical treatment were referred for PTSMA at our center. LV systolic and diastolic functions were assessed by online LV pressure-volume loops obtained by conductance catheter at baseline and at 6 months after the procedure. At follow-up, the mean gradients at rest and after extrasystole were significantly decreased compared with baseline (88 ± 29 to 21 ± 11 mm Hg and 130 ± 50 to 35 ± 22 mm Hg, respectively, p <0.01 for the 2 comparisons). End-systolic and end-diastolic pressures significantly decreased (p <0.01), whereas end-systolic and end-diastolic LV volumes significantly increased (p <0.01 for the 2 comparisons). Cardiac output and stroke volume were unchanged, as were ejection fraction (p = 0.25) and maximum dP/dt (p = 0.13). The slope of the end-systolic pressure-volume relation was not decreased, indicating a preserved contractility. The relaxation constant time, end-diastolic stiffness, projected volume of the end-diastolic pressure-volume relation at 30 mm Hg, and diastolic stiffness constant showed a significant improvement of active and passive myocardial diastolic properties. In conclusion, PTSMA is an effective method in the treatment of symptomatic patients with HC. At 6-month follow-up, the LV-aortic gradient was decreased and active and passive LV diastolic properties were increased. Myocardial contractility was not decreased and general hemodynamics was maintained.

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.

Early Detection of Left Ventricular Dysfunction by Doppler Tissue Imaging and N-terminal Pro-B-type Natriuretic Peptide in Patients with Symptomatic Severe Aortic Stenosis (Article)

2008-03-01T00:00:00Z

Background: Patients with severe aortic stenosis (AS) require valve replacement before development of irreversible left ventricular (LV) dysfunction. It has been postulated that Doppler tissue imaging (DTI) parameters are more sensitive to detect subtle LV dysfunction compared with conventional echocardiographic parameters. Objective: We sought to assess early LV dysfunction with DTI-derived echocardiographic parameters and N-terminal pro-B-type natriuretic peptide (NT-proBNP) in patients with severe AS and normal LV ejection fraction. Methods: A total of 29 patients (mean age 65 ± 12 years, 15 male) with symptomatic severe AS and 17 control subjects were included in the study. DTI was performed at the level of the mitral lateral (mlat) and septal (msep) annulus. Systolic (Sm), early (Em), and late (Am) diastolic velocities were measured, and E/Em ratio was calculated. NT-proBNP was determined by an electrochemiluminescence immunoassay. Results: Baseline characteristics between patients and control subjects were similar regarding LV ejection fraction and mitral inflow E/A ratio. However, patients with AS had significantly lower DTI values (Sm, Em, Am) compared with control subjects. Moreover, LV filling pressures, expressed by the E/Em ratio, were significantly higher in patients. Correlation analysis showed a relationship between the natural logarithm of NT-proBNP and aortic valve area, Smlat, and E/Emsepratio. Using stepwise multiple linear regression, Smlatwas found to be independently related to NT-proBNP. Conclusions: In patients with severe AS and normal LV ejection fraction, DTI showed LV systolic and diastolic dysfunction compared with control subjects. DTI-derived variables, and especially Smlat, were correlated with NT-proBNP levels.

The mild form of mucopolysaccharidosis type I (Scheie syndrome) is associated with increased ascending aortic stiffness (Article)

2008-03-01T00:00:00Z

Mucopolysaccharidosis type I (MPS IS) is a rare autosomal recessive disease caused by a deficiency of the lysosomal enzyme α-iduronidase, which is involved in the degradation of sulfated glycosaminoglycans (GAGs). The deficiency results in the intra-and pericellular accumulation of the GAGs heparan sulfate and dermatan sulfate. Eight adult patients with typical features of MPS IS aged 31.5 ± 6.8 years (five men) were included and compared to age-and gender-matched controls. With transthoracic echocardiography, cyclic ascending aortic diameter changes were measured and ascending aortic elastic properties were calculated to characterize aortic elasticity. In MPS IS patients, aortic stiffness index was significantly increased (23.1 ± 10.4 vs 3.9 ± 1.5, P < 0.001), while aortic distensibility was significantly decreased (1.6 ± 0.8 vs 1.6 ± 1.9 Ca2/dynes 10-6, P < 0.001) compared to age-and sex-matched controls. The results of the present study demonstrate that in addition to the known cardiac complications, MPS IS patients have an impairment of ascending aortic elasticity. Further follow-up studies are needed to examine arterial elasticity using other methods in this patient population, and to detect possible effects of enzyme replacement therapy.

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.

Determinants of coronary microvascular dysfunction in symptomatic hypertrophic cardiomyopathy (Article)

2008-02-01T00:00:00Z

Impaired hyperemic myocardial blood flow (MBF) in hypertrophic cardiomyopathy (HCM), despite normal epicardial coronary arteries, results in microvascular dysfunction. The aim of the present study was to determine the relative contribution of extravascular compressive forces to microvascular dysfunction in HCM. Eighteen patients with symptomatic HCM and normal coronary arteries and 10 age-matched healthy volunteers were studied with PET to quantify resting and hyperemic MBF at a subendocardial and subepicardial level. In HCM patients, MRI was performed to determine left ventricular (LV) mass index (LVMI) and volumes, echocardiography to assess diastolic perfusion time, heart catheterization to measure LV outflow tract gradient (LVOTG) and LV pressures, and serum NH2-terminal pro-brain natriuretic peptide (NT-proBNP) as a biochemical marker of LV wall stress. Hyperemic MBF was blunted in HCM vs. controls (2.26 ± 0.97 vs. 2.93 ± 0.64 ml·min-1·g-1, P < 0.05). In contrast to controls (1.38 ± 0.15 to 1.25 ± 0.19, P = not significant), the endocardial-to-epicardial MBF ratio decreased significantly in HCM during hyperemia (1.20 ± 0.11 to 0.88 ± 0.18, P < 0.01). This pattern was similar for hypertrophied septum and lateral wall. Hyperemic MBF was inversely correlated with LVOTG, NT-proBNP, left atrial volume index, and LVMI (all P < 0.01). Multivariate regression analysis, however, revealed that only LVMI and NT-proBNP were independently related to hyperemic MBF, with greater impact at the subendocardial myocardial layer. Hyperemic MBF is more severely impaired at the subendocardial level in HCM patients. The level of impairment is related to markers of increased hemodynamic LV loading conditions and LV mass. These observations suggest that, in addition to reduced capillary density caused by hypertrophy, extravascular compressive forces contribute to microvascular dysfunction in HCM patients. Copyright

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.

A new syndrome with noncompaction cardiomyopathy, bradycardia, pulmonary stenosis, atrial septal defect and heterotaxy with suggestive linkage to chromosome 6p (Article)

2008-01-01T00:00:00Z

We report a three-generation family with nine patients affected by a combination of cardiac abnormalities and left isomerism which, to our knowledge, has not been described before. The cardiac anomalies include non-compaction of the ventricular myocardium, bradycardia, pulmonary valve stenosis, and secundum atrial septal defect. The laterality sequence anomalies include left bronchial isomerism, azygous continuation of the inferior vena cava, polysplenia and intestinal malrotation, all compatible with left isomerism. This new syndrome is inherited in an autosomal dominant pattern. A genome-wide linkage analysis suggested linkage to chromosome 6p24.3-21.2 with a maximum LOD score of 2.7 at marker D6S276. The linkage interval is located between markers D6S470 (telomeric side) and D6S1610 (centromeric side), and overlaps with the linkage interval in another family with heterotaxy reported previously. Taken together, the genomic region could be reduced to 9.4 cM (12 Mb) containing several functional candidate genes for this complex heterotaxy phenotype.

An integrated approach to determine left atrial volume, mass and function in hypertrophic cardiomyopathy by two-dimensional echocardiography (Article)

2008-01-01T00:00:00Z

Methods: The study included 25 hypertrophic cardiomyopathy (HCM) patients (15 non-obstructive and 10 obstructive) and 25 controls for assessment of left atrial (LA) volume, mass and function by two-dimensional echocardiography. Measurement included mean LA diameter (LAD), LA mass = {(mean LAD + anterior LA wall + posterior LA wall)3- mean LAD3} × 0.8 + 0.6, LA volume = [(8/3 φ L ̇ A1 ̇ A2), where L is LA length, A1 and A2 are LA area in 4-chambers and 2-chambers, respectively] including maximum (Vmax), minimum (Vmin), and pre-atrial contraction (Vpre-A), total atrial stroke volume (TA-SV), TA emptying fraction (TA-EF), active atrial SV (AA-SV), AA-EF, passive atrial SV (PA-SV), PA-EF, atrial expansion index (AEI), and LA kinetic energy (LA-KE) = 1/2 × AA-SV × P × V2. Results: LAD, LA mass, Vmax, Vmin, and Vpre-Awere significantly higher in HCM than controls. TA-SV and TA-EF were comparable in both HCM subgroups and controls. AA-SV and LA-KE were significantly higher in both HCM subgroups than controls. LA-KE was significantly higher in obstructive HCM than non-obstructive (P < 0.001). PA-EF and AEI were significantly lower in obstructive HCM than controls (P < 0.05). Conclusion: HCM is associated with increased LA size and augmented LA pump function especially obstructive type. LA conduit and reservoir functions are impaired in obstructive HCM.

Alterations in aortic elasticity in noncompaction cardiomyopathy (Article)

2008-01-01T00:00:00Z

Background: Noncompaction cardiomyopathy (NCCM) is a recently recognized disorder frequently associated with systolic and diastolic heart failures. This study was designed to examine aortic stiffness in NCCM patients and to compare these results to age- and gender-matched controls. Methods: A total of 20 patients with typical echocardiographic features of NCCM (age 38 ± 16 years, eight males) were investigated. Their results were compared to 20 age- and gender-matched controls. All subjects underwent a complete two-dimensional transthoracic echocardiographic examination. Systolic (SD) and diastolic (DD) ascending aortic diameters were recorded in M-mode at a level of 3 cm above the aortic valve from a parasternal long-axis view. Aortic stiffness index (β) was calculated as a characteristic of aortic elasticity, as ln(SBP/DBP)/[(SD - DD)/DD], where SBP and DBP are the systolic and diastolic blood pressures, respectively, and ln is the natural logarithm. Results: The number of noncompacted segments in the NCCM patients was 4.6 ± 2.0. NCCM patients had significantly increased left ventricular dimensions and reduced left ventricular ejection fraction. Compared to controls, aortic stiffness index (β) was significantly increased in NCCM patients (8.3 ± 5.2 vs. 3.5 ± 1.1, p < 0.001). Conclusion: Increased aortic stiffness can be observed in patients with NCCM with moderate to severe heart failure. These alterations may be due to neurohormonal changes in heart failure.

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.

Assessment of normal tricuspid valve anatomy in adults by real-time three-dimensional echocardiography (Article)

2007-12-01T00:00:00Z

Background: The tricuspid valve (TV) is a complex structure. Unlike the aortic and mitral valve it is not possible to visualize all TV leaflets simultaneously in one cross-sectional view by standard two-dimensional echocardiography (2DE) either transthoracic or transesophageal due to the position of TV in the far field. Aim: Quantitative and qualitative assessment of the normal TV using real-time 3-dimensional echocardiography (RT3DE). Methods: RT3DE was performed for 100 normal adults (mean age 30 ± 9 years, 65% males). RT3DE visualization was evaluated by 4-point score (1: not visualized, 2: inadequate, 3: sufficient, and 4: excellent). Measurements included TV annulus diameters (TAD), TV area (TVA), and commissural width. Results: In 90% of patients with good 2DE image quality, it was possible to analyse TV anatomy by RT3DE. A detailed anatomical structure including unique description and measurement of tricuspid annulus shape and size, TV leaflets shape, and mobility, and TV commissural width were obtained in majority of patients. Identification of each TV leaflet as seen in the routine 2DE views was obtained. Conclusion: RT3DE of the TVis feasible in a large number of patients. RT3DE may add to functional 2DE data in description of TV anatomy and providing highly reproducible and actual reality (anatomical and functional) measurements.

Value of assessment of tricuspid annulus: Real-time three-dimensional echocardiography and magnetic resonance imaging (Article)

2007-12-01T00:00:00Z

Aim: To detect the accuracy of real-time three-dimensional echocardiography (RT3DE) and two-dimensional echocardiography (2DE) for tricuspid annulus (TA) assessment compared with magnetic resonance imaging (MRI). Methods: Thirty patients (mean age 34 ± 13 years, 60% males) in sinus rhythm were examined by MRI, RT3DE, and 2DE for TA assessment. End-diastolic and end-systolic TA diameter (TAD) and TA fractional shortening (TAFS) were measured by RT3DE, 2DE, and MRI. End-diastolic and end-systolic TA area (TAA) and TA fractional area changes (TAFAC) were measured by RT3DE and MRI. End-diastolic and end-systolic right ventricular (RV) volumes and ejection fraction (RV-EF) were measured by MRI. Results: The TA was clearly delineated in all patients and visualized as an oval-shaped by RT3DE and MRI. There was a good correlation between TADMRIand TAD3D(r = 0.75, P = 0.001), while TAD2Dwas fairly correlated with TAD3Dand TADMRI(r = 0.5, P = 0.01 for both). There were no significant differences between RT3DE and MRI in TAD, TAA, TAFS, and TAFAC measurements, while TAD2Dand TAFS2Dwere significantly underestimated (P < 0.001). TAFS2Dwas not correlated with RV-EF, while TAFS3Dand TAFAC3Dwere fairly correlated with RV-EF (r = 0.49, P = 0.01, and r = 0.47, P = 0.02 respectively). Conclusion: RT3DE helps in accurate assessment of TA comparable to MRI and may have an important implication in the TV surgical decision-making processes. RT3DE analysis of TA function could be used as a marker of RV function.

Response to the letter to the editor (Article)

2007-12-01T00:00:00Z

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.

Cardiac β-myosin heavy chain defects in two families with non-compaction cardiomyopathy: Linking non-compaction to hypertrophic, restrictive, and dilated cardiomyopathies (Article)

2007-11-01T00:00:00Z

Cardiomyopathies are classified according to distinct morphological characteristics. They occur relatively frequent and are an important cause of mortality and morbidity. Isolated ventricular non-compaction or non-compaction cardiomyopathy (NCCM) is characterized by an excessively thickened endocardial layer with deep intertrabecular recesses, reminiscent of the myocardium during early embryogenesis. Aims: Autosomal-dominant as well as X-linked inheritance for NCCM has been described and several loci have been associated with the disease. Nevertheless, a major genetic cause for familial NCCM remains to be identified. Methods and Results: We describe, in two separate autosomal-dominant NCCM families, the identification of mutations in the sarcomeric cardiac β-myosin heavy chain gene (MYH7), known to be associated with hypertrophic cardiomyopathy (HCM), restricted cardiomyopathy (RCM), and dilated cardiomyopathy (DCM). Conclusion: These results confirm the genetic heterogeneity of NCCM and suggest that the molecular classification of cardiomyopathies includes an MYH7-associated spectrum of NCCM with HCM, RCM, and DCM.

The prevalence and prognosis of unrecognized myocardial infarction and silent myocardial ischemia in patients undergoing major vascular surgery (Article)

2007-11-01T00:00:00Z

OBJECTIVE: The aim of this study is to determine the prevalence and prognosis of unrecognized myocardial infarction (MI) and silent myocardial ischemia in vascular surgery patients. METHODS: In a cohort of 1092 patients undergoing preoperative dobutamine stress echocardiography and noncardiac vascular surgery, unrecognized MI was determined by rest wall motion abnormalities in the absence of a history of MI. Silent myocardial ischemia was determined by stress-induced wall motion abnormalities in the absence of angina pectoris. Beta blockers and statins were noted at baseline. During follow-up (mean: 6±4 years), all-cause mortality and major cardiac events (cardiac death or nonfatal MI) were noted. RESULTS: The prevalence of unrecognized MI and silent myocardial ischemia was 23 and 28%, respectively. Both diabetes and heart failure were important predictors of unrecognized MI and silent myocardial ischemia. During follow-up, all-cause mortality occurred in 45% and major cardiac events in 23% of patients. In multivariate analysis, unrecognized MI and silent myocardial ischemia were significantly associated with increased risk of mortality [hazard ratio (HR), 1.86; 95% confidence interval (CI), 1.53-2.25 and HR, 1.74; 95% CI, 1.46-2.06, respectively] and major cardiac events (HR, 2.15; 95% CI, 1.59-2.92 and HR, 1.86; 95% CI, 1.43-2.41, respectively). In patients with unrecognized MI, β-blockers and statins were significantly associated with improved survival. Statins improved survival in patients with silent myocardial ischemia. CONCLUSIONS: In patients undergoing major vascular surgery, unrecognized MI and silent myocardial ischemia are highly prevalent (23 and 28%) and associated with increased long-term mortality and major cardiac events.

Left atrial Frank-Starling law assessed by real-time, three-dimensional echocardiographic left atrial volume changes (Article)

2007-11-01T00:00:00Z

Background: The Frank-Starling law describes the relation between left ventricular volume and function. However, only a few studies have described the relation between left atrial volume (LAV) and function. Objective: To describe an LA Frank-Starling law by studying changes in LAV measured by real-time, three-dimensional echocardiography (RT3DE). Methods: LAV was calculated by RT3DE in 70 patients at end-systole (LAVmax), end-diastole (LAVmin) and pre-atrial contraction (LAVpre-A). According to LAVmax, patients were classified into three groups: LAVmax<50 ml (group I), LAVmax50-70 ml (group II) and LAVmax>70 ml (group III). Calculated indices of LA pump function were active atrial stroke volume (SV), defined as LAVpre-A- LAVmin, and active atrial emptying fraction (EF), defined as active atrial SV/LAVpre-Ax100% Results: Active atrial SV was significantly higher in group II than in group I (mean (SD) 19.0 (9.2) vs 8.2 (4.9) ml, p<0.0001), in group III it was non-significantly lower than in group II (16.7 (12.5) vs 19.0 (9.2) ml). Active atrial SV correlated well with LAVpre-A(r = 0.56, p<0.001), but decreased with larger LAVpre-A. Active atrial EF tended to be higher in group II than in group I (43.1 (18.2) vs 33.2 (17.5), p<0.10), in group III it was significantly lower than in group II (26.2 (18.5) vs 43.1 (18.2), p<0.01). Conclusion: A Frank-Starling mechanism in the left atrium could be described by RT3DE, shown by an increase in LA contractility in response to an increase in LA preload up to a point, beyond which LA contractility decreased.

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.

The additional prognostic power of diabetes mellitus on coronary flow reserve in patients with suspected coronary artery disease (Article)

2007-10-01T00:00:00Z

Aims: The aim of the present study was to assess the relative prognostic value of coronary flow reserve (CFR) and diabetes mellitus (DM) in patients with suspected coronary artery disease (CAD). Methods: We prospectively studied 347 inhospital patients with chest pain. Coronary angiography was performed in 281 patients (81%). All patients underwent a transthoracic echocardiographic study to evaluate left ventricular function and a stress vasodilator transoesophageal echocardiographic study to evaluate simultaneously CFR and the degree of aortic atherosclerosis (AA). The primary outcome of the study was cardiovascular mortality. Results: During a mean follow-up of 41 ± 12 months, 22 patients suffered cardiovascular death. Diabetic patients had a significantly higher AA grade and tended to have a lower CFR and more often significant CAD. Patients with normal CFR had less often significant CAD and tended to have less often DM. Significant univariable predictors of cardiovascular survival were DM, LV end-diastolic diameter, CFR and AA grade. Multivariable regression analysis showed that only CFR (hazard ratio (HR) 2.9, P = 0.01) and diabetes (HR 3.1, P = 0.01) were independent predictors of cardiovascular survival. Conclusions: CFR and DM evaluations offer complementary information during vasodilator stress TEE testing. Patients with reduced CFR (impaired microcirculatory function) and DM have the worst prognosis.

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.

True mitral annulus diameter is underestimated by two-dimensional echocardiography as evidenced by real-time three-dimensional echocardiography and magnetic resonance imaging (Article)

2007-10-01T00:00:00Z

Background: Mitral annulus assessment is of great importance for the diagnosis and treatment of mitral valve disease. The present study sought to assess the value of real-time three-dimensional echocardiography for the assessment of true mitral annulus diameter (MAD). Methods: One hundred and fifty patients (mean age 38 ± 18 years) with adequate two-dimensional (2D) echocardiographic image quality underwent assessment of MAD2Dand MAD3D(with real-time three-dimensional echocardiography). In a subgroup of 30 patients true MAD was validated with magnetic resonance imaging (MRI). Results: There was a good interobserver agreement for MAD2D(mean difference = -0.25 ± 2.90 mm, agreement: -3.16, 2.66) and MAD3D(mean difference = 0.29 ± 2.03, agreement = -1.74, 2.32). Measurements of MAD2Dand MAD3Dwere well correlated (R = 0.81, P < 0.0001). However, MAD3Dwas significantly larger than MAD2D(3.7 ± 0.9 vs. 3.3 ± 0.8 cm, P < 0.0001). In the subgroup of 30 patients with MRI validation, MAD3Dand MADMRIwere significantly larger than MAD2D(3.3 ± 0.5 and 3.4 ± 0.5 cm vs. 2.9 ± 0.4 cm, both P < 0.001). There was no significant difference between MADMRIand MAD3D. Conclusion: MAD3Dcan be reliably measured and is superior to MAD2Din the assessment of true mitral annular size.

Three-dimensional echocardiographic analysis of left ventricular function during hemodialysis (Article)

2007-10-01T00:00:00Z

Background: The effects of hemodialysis (HD) on left ventricular (LV) function have been studied by various echocardiographic techniques (M-mode, 2D echocardiography). These studies are hampered by a low accuracy of measurements because of geometric assumptions regarding LV shape. Three-dimensional echocardiography (3DE) overcomes this limitation. Methods: We tested the feasibility of 3DE assessment of LV function during HD. Conventional biplane Simpson rule (BSR) and single plane area length method (SPM) for LV function analysis were used as a reference. Results: 12 HD patients were studied and in 10 (83%) a total of 80 3D datasets were acquired. In 3 patients, one dataset (4%) was of insufficient quality and excluded from analysis. Correlation between SPM, BSR and 3DE for calculation of end-diastolic (EDV, r = 0.89 and r = 0.92, respectively), end-systolic volume (ESV, r = 0.92 and r = 0.93, respectively) and for ejection fraction (EF, r = 0.90 and r = 0.88, respectively) was moderate. Limits-of-agreement results for EDV and ESV were poor with confidence intervals larger than 30 ml. Both 2DE methods underestimated end-diastolic and end-systolic volume, while overestimating ejection fraction. Conclusion: 3DE is feasible for image acquisition during HD, which opens the possibility for accurate and reproducible measurement of LV function during HD. This may improve the assessment of the acute effect of HD on LV performance, and guide therapeutic strategies aimed at preventing intradialytic hypotension. Copyright

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.

Increased aortic stiffness in glycogenosis type 2 (Pompe's disease) (Article)

2007-08-09T00:00:00Z

Background: Pompe's disease, also known as acid maltase deficiency or glycogen storage disease type II, is an autosomal recessive disorder in which deficient activity of the enzyme acid α-glucosidase causes intra-lysosomal accumulation of glycogen in muscle and other tissues. The current study was designed to assess aortic stiffness index (β), as a characteristic of aortic elasticity during transthoracic echocardiography in patients with Pompe's disease. Methods: A total of 17 patients (age 44 ± 8 years, 5 males) with Pompe's disease were studied. Their results were compared to 17 age- and gender-matched controls. In all patients, the ascending aorta was recorded with M-mode echocardiography. β was calculated as ln(SBP/DBP)/[(SD-DD)/DD], where SBP and DBP are the systolic and diastolic blood pressures, SD and DD are the systolic and diastolic aortic diameters, and 'ln' is the natural logarithm. Results: Diastolic aortic diameter was 27.4 ± 2.4 mm in Pompe patients and 25.6 ± 2.7 mm in controls (P < 0.05). Systolic aortic diameters did not differ between the groups (29.4 ± 2.5 mm vs 28.3 ± 2.4 mm, P = ns). Aortic stiffness index (β) was increased in Pompe patients compared to controls (14.6 ± 10.1 vs 5.1 ± 2.6, P < 0.001). Conclusions: The results of this study indicate that aortic stiffness is increased in patients with Pompe's disease. This may be due to glycogen storage in the vessel wall causing reduced vascular elasticity.

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 Mitral Annulus Size and Function by Real-time 3-Dimensional Echocardiography in Cardiomyopathy: Comparison with Magnetic Resonance Imaging (Article)

2007-08-01T00:00:00Z

Objective: We sought to assess mitral annular (MA) size and function in hypertrophic cardiomyopathy (HCM) and dilated cardiomyopathy (DCM) using real-time 3-dimensional (3D) echocardiography (RT3DE). Methods: The study included 30 patients with HCM, 20 patients with DCM, and 30 control subjects. RT3DE measurements included end-systolic and end-diastolic MA area (MAA) (MAA3D), MA diameter3D, MA fractional area change (MAFAC), and MA fractional shortening. In subgroup of 50 patients, magnetic resonance imaging (MRI) was used for MAAMRIand MA diameterMRImeasurement. Results: End-diastolic MAA3Dwas larger in HCM than in control group (P < .0001). Higher MAFAC and MA fractional shortening were present in HCM than in control group (P = .001 and P = .006, respectively). End-systolic and end-diastolic MAA3Din DCM were higher than in HCM and control groups (P < .0001). Lower MAFAC and MA fractional shortening were present in DCM than in HCM and control groups (P < .0001). MAFAC correlated well with left ventricular function in control subjects (r = 0.94, P < .0001), whereas correlation was less in DCM (r = 0.53, P = .02) and HCM (r = 0.42, P < .01). RT3DE and MRI measurements were comparable. Conclusion: RT3DE assessment of MA size and function in control subjects and patients with cardiomyopathy is accurate and well correlated with MRI.

Can echocardiographic findings predict falls in older persons? (Article)

2007-07-25T00:00:00Z

Background. The European and American guidelines state the need for echocardiography in patients with syncope. 50% of older adults with syncope present with a fall. Nonetheless, up to now no data have been published addressing echocardiographic abnormalities in older fallers. Method and Findings. In order to determine the association between echocardiographic abnormalities and falls in older adults, we performed a prospective cohort study, in which 215 new consecutive referrals (age 77.4 SD 6.0) of a geriatric outpatient clinic of a Dutch university hospital were included. During the previous year, 139 had experienced a fall. At baseline, all patients underwent routine two-dimensional and Doppler echocardiography. Falls were recorded during a three-month follow-up. Multivariate adjustment for compounders was performed with a Cox proportional hazards model. 557 patients (26%) fell at least once during follow-up. The adjusted hazard ratio of a fall during follow-up was 135 (95% Cl, 1.08-1.71) for pulmonary hypertension, 1.66 (95% Cl, 1.01 to 2.89) for 4-initial regurgitation, 2.41 (95% Cl, 1.32 to 4.37) for tricuspid regurgitation and 1.76 (95% Cl, 1.03 to 3.01) for pulmonary regurgitation. For aoitic regurgitation the risk of a fall was also increased, but non-significantly. (hazard ratio, 1.57 [95% Cl 0.85 to 2.92]). Trend analysis of the severity of the difterent regurgitations showed a significant relationship for mitral, tricuspid and pulmonary valve regurgitation and pulmonary hypertension. Conclusions. Echo(Dopler)cardiography can be useful in order to identify risk indicators for falling. Presence of pulmonary hypertension or regurgitation of mitral, tricuspid or pulmonary valves was associated with a higher fall risk. Our study indicates that the diagnostic work-up for falls in older adults might be improved by adding an echo(Doppler)cardiogram in selected groups.

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.

The use of contrast echocardiography for the detection of cardiac shunts (Article)

2007-06-01T00:00:00Z

Recently, debate has erupted about the clinical significance of cardiovascular shunts. Several major health problems such as stroke and migraine have been associated with patent foramen ovale (PFO) with right-to-left shunt (RLS). The nature of the relationship between these syndromes and PFO is not clearly understood. Technical advances have led to more therapeutic options including device closure of PFO, hence prevention of such a PFO-related stroke has become feasible. Therefore, optimal diagnosis of PFO has become of greater clinical importance. Contrast echocardiography with non-transpulmonary contrast agents has been the cornerstone in diagnosis of PFO with RLS for over four decades. Despite being a relatively invasive procedure, transesophageal echocardiography (TEE) is considered the gold standard for detection of RLS. Several other echocardiographic techniques such as transthoracic echocardiography (TTE) with second harmonic imaging and transcranial Doppler ultrasonography (TCD) have shown increased sensitivity and specificity compared to TEE for the detection of PFO with RLS. Moreover, improvement of skills and techniques used for detection of these shunts has led to greater detection of small and large sized RLS in the echocardiographic laboratory. This review gives and overview of the echocardiographic techniques, contrast agents and manoeuvres used for detection of the major cardiovascular shunts and their clinical relevance to major health problems.

Diagnostic value of dobutamine stress echocardiography in patients with normal wall motion at rest (Article)

2007-05-01T00:00:00Z

Efficient Quantification of the Left Ventricular Volume Using 3-Dimensional Echocardiography: The Minimal Number of Equiangular Long-axis Images for Accurate Quantification of the Left Ventricular Volume (Article)

2007-04-01T00:00:00Z

For quantification of the left ventricular volume from 3-dimensional echocardiograms a number of cross-sectional images are used. The goal of this study was to determine the minimum number of long-axis images necessary for accurate quantification of the left ventricular volume. A strong correlation was observed between volumes obtained from magnetic resonance imaging and 3-dimensional echocardiography using 16 equiangular images (r = 0.99; y = 0.95x + 3.3 mL; standard error of the estimate = 7.0 mL; N = 30). Comparison of these results with random subsets showed a significant difference for volumes obtained with 4 and 2 equiangular images (P < .005). However, when the subsets were selected to target the eccentric region of the endocardial border this was only the case for subsets of two images (P < .001). This study demonstrates that accurate left ventricular volume quantification can be performed with as little as 8 equiangular long-axis images. By selecting the correctly oriented image set, this number can even be brought down to 4, which will further reduce the analysis time.

Assessment of pulmonary valve and right ventricular outflow tract with real-time three-dimensional echocardiography (Article)

2007-04-01T00:00:00Z

Aim: Assessment of pulmonary valve (PV) and right ventricular outflow tract (RVOT) using real-time 3-dimensional echocardiography (RT3DE). Methods: Two-dimensional echocardiography (2DE) and RT3DE were performed in 50 patients with congenital heart disease (mean age 32 ± 9.5 years, 60% female). Measurements were obtained at parasternal views: short axis (PSAX) at aortic valve level and long axis (PLAX) with superior tilting. RT3DE visualization was evaluated by 4-point score (1: not visualized, 2: inadequate, 3: sufficient, and 4: excellent). Diameters of PV annulus (PVAD), and RVOT (RVOTD) were measured by both 2DE and RT3DE, while areas (PVAA) and (RVOTA) by RT3DE only. Results: By RT3DE, PV was visualized sufficiently in 68% and RVOTexcellently in 40%. PVAD and PVAA were measured in 88%. RVOTD and PVAD by 2DE at PLAX were significantly higher than PSAX (P < 0.0001) and lower than that by RT3DE (P < 0.001). Conclusion: RT3DE helps inRVOT and PV assessment adding more details supplemental to 2DE.

Dobutamine Stress Echocardiography for the Detection of Coronary Artery Disease in Women (Article)

2007-03-01T00:00:00Z

Dobutamine stress echocardiography (DSE) has good diagnostic accuracy for the diagnosis of coronary artery disease (CAD). However, in most published diagnostic studies, patients are predominantly men. In women, diagnostic accuracy may be lower because of a lower prevalence and extent of CAD, a higher incidence of dobutamine stress-induced hypotension (resulting in less stress or even nondiagnostic test results), smaller left ventricular chamber size, and the beneficial effects of estrogens on the induction of myocardial ischemia. To determine the diagnostic accuracy of DSE in women, 14 diagnostic studies published through 2006 were identified through a Medline search. For a total of 901 patients, the weighted mean sensitivity and specificity were 72% and 88%, respectively. In 7 studies directly comparing results in women and men, conflicting results were reported. However, pooled data showed nearly identical values for sensitivity and specificity in women and men. Additionally, in 6 studies directly comparing DSE results in women with those of stress nuclear scintigraphy, DSE was as sensitive and more specific to detect CAD (90% vs 70%, p <0.0001). The excellent specificity of DSE in women was also confirmed by excellent normalcy rates, ranging from 92% to 100% in women, with a <5% pretest probability of CAD. In conclusion, despite some theoretical limitations, DSE has reasonable sensitivity and excellent specificity for the detection of CAD in women. Considering the diagnostic problems of exercise electrocardiography and nuclear scintigraphy in women, stress echocardiography may be the stress modality of choice in women because of its superior diagnostic specificity.

Evaluation of rheumatic tricuspid valve stenosis by real-time three-dimensional echocardiography (Article)

2007-03-01T00:00:00Z

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.

Three-Dimensional Echocardiographic Analysis of Left Ventricular Function during Hemodialysis (Article)

2007-01-01T00:00:00Z

Aortic valve replacement for aortic stenosis is associated with improved aortic distensibility at long-term follow-up (Article)

2007-01-01T00:00:00Z

Background: Aortic valve stenosis (AS) is the most frequent form of valvular heart disease. The number of studies evaluating the effect of aortic valve replacement (AVR) for AS on aortic vascular function is limited. The aim of the present study was to examine alterations in aortic distensibility in patients with AS during a 1-year follow-up after AVR. Methods: Twelve patients with severe AS who underwent AVR were prospectively examined (mean age 65 ± 11 years, 7 men). Systolic and diastolic ascending aortic diameters (SD and DD, respectively) were recorded in M mode 3 cm above the aortic valve from a parasternal long-axis view. The SD and DD were measured at the time of maximum anterior motion of the aorta and at the start of the QRS complex, respectively. Aortic stiffness index (β) was defined as [ln(SBP/DBP)] × DD/ΔD, where ln is the natural logarithm, SBP and DBP are the systolic and diastolic blood pressure values, respectively, and ΔD = SD - DD. Results: As expected, aortic stenosis severity and left ventricular mass decreased significantly after AVR. Aortic diameter changes (systolic minus diastolic dimensions) progressively increased and the aortic stiffness index progressively improved to levels comparable with those of age-, sex-, and risk factor-matched controls at the 1-year assessment. Conclusions: Aortic valve replacement in patients with AS is associated with a progressive improvement in aortic distensibility to 1-year values similar to those of controls.

Wide spectrum of presentation and variable outcomes of isolated left ventricular non-compaction (Article)

2007-01-01T00:00:00Z

Objectives: To investigate diagnostic routes, echocardiographic substrates, outcomes and prognostic factors in patients with isolated ventricular non-compaction (IVNC) identified by echocardiographic laboratories with referral from specialists and primary care physicians. Patients and design: Since 1991, all patients with suspected IVNC were flagged and followed up on dedicated databases. Patients were divided into symptom-based and non-symptom-based diagnostic subgroups. Results: 65 eligible patients were followed up for 6-193 months (mean 46 (SD 44). In 53 (82%) patients, IVNC was associated with variable degrees of left ventricular (LV) dilatation and hypokinesia, and in the remaining 12 (18%) LV volumes were normal. Diagnosis was symptom based in 48 (74%) and non-symptom based in 17 (26%) (familial referral in 10). The non-symptom-based subgroup was characterised by younger age, lower prevalence of ECG abnormalities, better systolic function and lower left atrial size, whereas the extent of non-compaction was not different. No major cardiovascular events occurred in the non-symptom-based group, whereas 15 of 48 (31%) symptomatically diagnosed patients experienced cardiovascular death or heart transplantation (p = 0.01, Kaplan-Meier analysis). Independent predictors of cardiovascular death or heart transplantation were New York Heart Association class HI-IV, sustained ventricular arrhythmias and left atrial size. Conclusions: IVNC is associated with a broad spectrum of clinical and pathophysiological findings, and the overall natural history and prognosis may be better than previously thought. Adult patients with incidental or familial discovery of IVNC have an encouraging outlook, whereas those who have symptoms of heart failure, a history of sustained ventricular tachycardia or an enlarged left atrium have an unstable course and more severe prognosis.

Ablation lesions in Koch's triangle assessed by three-dimensional myocardial contrast echocardiography. (Article)

2004-12-09T00:00:00Z

BACKGROUND: Myocardial contrast echocardiography (MCE) allows visualization of radiofrequency (RF) ablation lesions in the left ventricle in an animal model. Aim: To test whether MCE allows visualization of RF and cryo ablation lesions in the human right atrium using three-dimensional echocardiography. METHODS: 18 patients underwent catheter ablation of a supraventricular tachycardia and were included in this prospective single-blind study. Twelve patients were ablated inside Koch's triangle and 6, who served as controls, outside this area. Three-dimensional echocardiography of Koch's triangle was performed before and after the ablation procedure in all patients, using respiration and ECG gated pullback of a 9 MHz ICE transducer, with and without continuous intravenous echocontrast infusion (SonoVue, Bracco). Two independent observers analyzed the data off-line. RESULTS: MCE identified ablation lesions as a low contrast area within the normal atrial myocardial tissue. Craters on the endocardial surface were seen in 10 (83%) patients after ablation. Lesions were identified in 11 out of 12 patients (92%). None of the control patients were recognized as having been ablated. The confidence score of the independent echo reviewer tended to be higher when the number of applications increased. CONCLUSIONS: 1. MCE allows direct visualization of ablation lesions in the human atrial myocardium. 2. Both RF and cryo energy lesions can be identified using MCE.

Diastolic coronary vascular reserve: a new index to detect changes in the coronary microcirculation in hypertrophic cardiomyopathy. (Article)

2004-02-18T00:00:00Z

OBJECTIVES: The present study introduces a modification of the diastolic coronary conductance concept that maintains its sensitive properties to detect changes in the coronary microcirculation in human hypertrophy. BACKGROUND: Decrements of coronary flow in hypertrophy have been explained by changes in the coronary microcirculation. No measure is available to detect these changes. METHODS: Doppler velocity catheters were introduced into the left anterior descending artery (LAD) and left circumflex coronary artery (LCx) of patients with obstructive hypertrophic cardiomyopathy (HCM) (n = 11) and into the LAD of cardiac transplant recipients (n = 9). The diastolic coronary conductance was measured at rest and after maximal hyperemia induced by a bolus injection of adenosine. Diastolic coronary vasodilator reserve (DCVR) was calculated as the hyperemic diastolic coronary conductance, divided by the coronary conductance during resting conditions. RESULTS: Left ventricular outflow tract gradient in the HCM group (83 +/- 31 mm Hg) was significantly higher (p < 0.05). Septal wall thickness was significantly increased (p < 0.05), while wall thickness was unchanged in the posterior wall of the HCM group. The coronary flow reserve was significantly decreased in the HCM-LCx region (to 64 +/- 7% of control) and in the HCM-LAD regions (to 57 +/- 7% of control). The DCVR was only decreased in the HCM-LAD (to 46 +/- 3% of control) and not in the HCM-LCx group (86 +/- 6%, p > 0.05). Esmolol did affect the pressure gradient and systolic shortening, but did not affect the maximal diastolic conductance. CONCLUSIONS: The DCVR, in contrast with the coronary flow reserve, is decreased in those regions that display a disturbance in the microcirculation and may, therefore, offer a new way to study coronary adaptations in patients with hypertrophy.

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.

Angiotensin II type 2 receptors and cardiac hypertrophy in women with hypertrophic cardiomyopathy (Article)

2001-01-01T00:00:00Z

The development of left ventricular hypertrophy in subjects with hypertrophic cardiomyopathy (HCM) is variable, suggesting a role for modifying factors such as angiotensin II. Angiotensin II mediates both trophic and antitrophic effects, via angiotensin II type 1 (AT(1)-R) and angiotensin II type 2 (AT(2)-R) receptors, respectively. Here we investigated the effect of the AT(2)-R gene A/C(3123) polymorphism, located in the 3' untranslated region of exon 3, on left ventricular mass index (LVMI) in 103 genetically independent subjects with HCM (age, 12 to 81 years). LVMI and interventricular septum thickness were determined by 2D echocardiography. Extent of hypertrophy was quantified by a point score (Wigle score). Plasma prorenin, renin, and ACE were determined by immunoradiometric or fluorometric assays, and genotyping was performed by polymerase chain reaction. In men, no associations between AT(2)-R genotype and any of the measured parameters were observed, whereas in women, LVMI decreased with the number of C alleles (211+/-19, 201+/-18, and 152+/-10 g/m(2) in women with the AA, AC, and CC genotype, respectively; P=0.015). Similar C allele-related decreases in women were observed for interventricular septum thickness (P=0.13), Wigle score (P=0.05), plasma renin (P=0.03), and plasma prorenin (P=0.26). Multiple regression analysis revealed that the AT(2)-R C allele-related effect on LVMI (beta=-30.7+/-11.1, P=0.010) occurred independently of plasma renin, the AT(1)-R gene A/C(1166) polymorphism, or the ACE gene I/D polymorphism. In conclusion, AT(2)-Rs modulate cardiac hypertrophy in women with HCM, independently of the circulating renin-angiotensin system. These data support the contention that AT(2)-Rs mediate antitrophic effects in humans.

Decreased coronary flow reserve in hypertrophic cardiomyopathy is related to remodeling of the coronary microcirculation. (Article)

1998-01-01T00:00:00Z

Background—Ischemia occurs frequently in hypertrophic cardiomyopathy (HCM) without evidence of epicardial stenosis. This study evaluates the hypothesis that the occurrence of ischemia in HCM is related to remodeling of the coronary microcirculation. Methods and Results—End-diastolic septal wall thickness was significantly increased in patients with HCM (25.8±2.9 mm) in comparison with cardiac transplant recipients (control subjects: 11.4±3.0 mm; P<0.05). Although the diameter of the left anterior descending coronary artery was similar in both groups (3.0±0.8 versus 3.0±0.5 mm, P=NS), the coronary resistance reserve (CRR=CRRbasal/CRRhyperemic), corrected for extravascular compression (end-diastolic left ventricular pressure), was reduced to 1.5±0.6 in HCM (P<.05; control, 2.6±0.8). Arteriolar lumen (AL) divided by wall area was lower in HCM (21±5% versus 30±4%; P<.05), and capillary density tended to decrease (from 1824±424 to 1445±513 per mm2, P=.11) in HCM. CRR was linearly related to normalized AL according to the formula CRR=0.1 AL-0.45 (r=.57; P<.05). Further analysis revealed that CRR, AL, and capillary density were all linearly related to the degree of hypertrophy. Conclusions—Decrements in CRR were related to changes of the coronary microcirculation. Both the decrease in CRR and these changes in the coronary microcirculation were related to the degree of hypertrophy. All these factors might contribute to the well-known occurrence of ischemia in this patient group.

Decreased coronary flow reserve in hypertrophic cardiomyopathy is related to remodeling of the coronary microcirculation (Article)

1998-01-01T00:00:00Z

BACKGROUND: Ischemia occurs frequently in hypertrophic cardiomyopathy (HCM) without evidence of epicardial stenosis. This study evaluates the hypothesis that the occurrence of ischemia in HCM is related to remodeling of the coronary microcirculation. METHODS AND RESULTS: End-diastolic septal wall thickness was significantly increased in patients with HCM (25.8+/-2.9 mm) in comparison with cardiac transplant recipients (control subjects: 11.4+/-3.0 mm; P<0.05). Although the diameter of the left anterior descending coronary artery was similar in both groups (3.0+/-0.8 versus 3.0+/-0.5 mm, P=NS), the coronary resistance reserve (CRR=CRRbasal/CRRhyperemic), corrected for extravascular compression (end-diastolic left ventricular pressure), was reduced to 1.5+/-0.6 in HCM (P<.05; control, 2.6+/-0.8). Arteriolar lumen (AL) divided by wall area was lower in HCM (21+/-5% versus 30+/-4%; P<.05), and capillary density tended to decrease (from 1824+/-424 to 1445+/-513 per mm2, P=.11) in HCM. CRR was linearly related to normalized AL according to the formula CRR=O.1 AL-0.45 (r=.57; P<.05). Further analysis revealed that CRR, AL, and capillary density were all linearly related to the degree of hypertrophy. CONCLUSIONS: Decrements in CRR were related to changes of the coronary microcirculation. Both the decrease in CRR and these changes in the coronary microcirculation were related to the degree of hypertrophy. All these factors might contribute to the well-known occurrence of ischemia in this patient group.

AT1 receptor A/C1166 polymorphism contributes to cardiac hypertrophy in subjects with hypertrophic cardiomyopathy (Article)

1998-01-01T00:00:00Z

The development of left ventricular hypertrophy (LVH) in subjects with hypertrophic cardiomyopathy (HCM) is variable, suggesting a role for modifying factors such as angiotensin II. We investigated whether the angiotensin II type 1 receptor (AT1-R) A/C1166 polymorphism, the angiotensin-converting enzyme (ACE) insertion/deletion (I/D) polymorphism, and/or plasma renin influence LVH in HCM. Left ventricular mass index (LVMI) and interventricular septal thickness were determined by 2-dimensional echocardiography in 104 genetically independent subjects with HCM. Extent of hypertrophy was quantified by a point score (Wigle score). Plasma prorenin, renin, and ACE were measured by immunoradiometric or fluorometric assays, and ACE and AT1-R genotyping were performed by polymerase chain reactions. The ACE D allele did not affect any of the measured parameters except plasma ACE (P<0.04). LVMI was higher (P<0.05) in patients carrying the AT1-R C allele (190+/-8.3 g/m2) than in AA homozygotes (168+/-7.2 g/m2), and similar patterns were observed for interventricular septal thickness (23.0+/-0.7 versus 21. 6+/-0.7 mm) and Wigle score (7.0+/-0.3 versus 6.3+/-0.3). Plasma renin was higher (P=0.05) in carriers of the C allele than in AA homozygotes. Multivariate regression analysis, however, revealed no independent role for renin in the prediction of LVMI. Plasma prorenin and ACE were not affected by the AT1-R A/C1166 polymorphism, nor did the ACE and AT1-R polymorphisms interact with regard to any of the measured parameters. We conclude that the AT1-R C1166 allele modulates the phenotypic expression of hypertrophy in HCM, independently of plasma renin and the ACE I/D polymorphism.

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.

Intracoronary Albunex. Its effects on left ventricular hemodynamics, function, and coronary sinus flow in humans (Article)

1993-01-01T00:00:00Z

Is the rate of disappearance of echo contrast from the interventricular septum a measure of left anterior descending coronary artery stenosis (Article)

1988-01-01T00:00:00Z

Although myocardial contrast echo has been used recently in human studies, no study is available at the present time which relates contrast echo findings to the degree of coronary artery stenosis. The present study is the first attempt to determine whether a quantitative relationship exists between regional myocardial echo contrast disappearance rate ('washout') and the severity of coronary artery stenosis. Manual injection of sonicated iopamidol (Iopamiro 370) into the left main coronary artery with simultaneous cross-sectional echo registration provided the myocardial echo-contrast images. From the digitized images, an echo contrast time-intensity curve was constructed for the proximal basal interventricular septum (region I) and the mid-distal portion of the interventricular septum (region II). From these curves, T50 was calculated after Fourier transformation and mono-exponential curve fitting. The percentage stenosis area (%A) of the left descending coronary artery (LAD) was calculated from routine coronary arteriograms using a computer-based system. Thirty patients (22 men, 8 women; mean age 58 +/- 10 years) were included in the study. Group I (n = 7) had normal LAD, group II (n = 18) had LAD stenosis of varying degrees. Five patients were not suitable for quantitative evaluation. A curvilinear relation was found between T50 and %A. (T50 = 3.0 x e0.01%A; r = 0.78; P less than 0.05). Patients with asynergy had significantly longer T50 (8.2 +/- 2.5 s) than did patients without asynergy (4.2 +/- 1.5 s) (P less than 0.05). All patients with greater than 75% LAD %A had prolonged T50. T50 might be useful index for studying regional myocardial perfusion during cardiac catheterization.

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.

Coronary flow reserve and diastolic dysfunction in hypertrophic cardiomyopathy (Article)

1987-01-01T00:00:00Z

We studied 14 patients with hypertrophic cardiomyopathy during and after atrial pacing by simultaneous registration of left ventricular high fidelity pressure measurements and M-mode echocardiography together with great cardiac vein flow measured by thermodilution. Heart rate rose from 75 +/- 18 to 142 +/- 14 beats/minute with an increase of 93 +/- 30 to 127 +/- 46 milliliters/minute of great cardiac vein flow (increase of flow/beat: 0.8 versus 1.5 milliliters/beat in normal individuals; P less than 0.05). In addition, diastolic hemodynamic parameters (such as left ventricular end-diastolic pressure, T1 (time constant of relaxation) (of first 40 milliseconds) and T2 (of second 40 milliseconds) and LVdP/dt-) changed from, respectively, 27.4 +/- 7.1 to 24.0 +/- 10.3 mm Hg; (NS), 67.3 +/- 16.1 to 65.7 +/- 22.2 liters/second; (NS) 68.6 +/- 36.9 to 52.9 +/- 19.4 (P less than 0.05), and 1592 +/- 75 to 1302 +/- 48 mm Hg/sec; P less than 0.05. Left ventricular end-diastolic dimensions decreased whereas end-diastolic wall thickness increased from, respectively, 37 +/- 3 to 34 +/- 4 millimeters; (P less than 0.05) and 14 +/- 2 to 17 +/- 1 millimeters (P less than 0.05). Eleven of the 14 patients experienced angina pectoris concomitant with ST-T depression of 1 millimeter or more on the electro-cardiogram. No correlations were found between great cardiac venous flow and hemodynamically or ultrasonically derived diastolic parameters of left ventricular function.

An elusive persistent left superior vena cava draining into left atrium (Article)

1986-01-01T00:00:00Z

A case report of a persistent left superior vena cava draining into left atrium with a fibromuscular left ventricular outflow tract obstruction and a small atrial septal defect. The anomalous vessel escaped detection during two right and left heart catheterizations from the right arm and open heart surgery. It was an incidental finding during cardiac catheterization from the left arm and the anatomy was confirmed by contrast echocardiography.

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.

Effects of short-term administration of verapamil on left ventricular relaxation and filling dynamics measured by a combined hemodynamic-ultrasonic technique in patients with hypertrophic cardiomyopathy (Article)

1983-01-01T00:00:00Z

The effects of short-term administration of verapamil on left ventricular isovolumetric relaxation and early and late diastolic filling dynamics were studied in 10 patients with hypertrophic cardiomyopathy by a combined hemodynamic-ultrasonic technique. Left ventricular pressures (recorded with high-fidelity micromanometers) were determined simultaneously with M mode echocardiography. After 10 mg of verapamil was given intravenously (2 mg/min), left ventricular contractility and systolic pressure dropped significantly (p less than .05). Left ventricular dP/dt fell from 1947 +/- 544 to 1489 +/- 334 mm Hg/sec, maximal velocity of the contractile element at zero load fell from 50 +/- 17 to 42 +/- 15 1/sec, peak velocity contraction of the contractile element fell from 37 +/- 10 1/sec to 29 +/- 10 1/sec (p less than .05), and left ventricular systolic pressure fell from 149 +/- 30 to 127 +/- 22 mm Hg. Left ventricular negative dP/dt increased from 1770 +/- 479 to 1477 +/- 377 mm Hg/sec (p less than .05), and the time constant of isovolumetric pressure decay was prolonged from 48 +/- 9 to 64 +/- 15 msec (p less than .05). Left ventricular end-diastolic pressure rose from 21 +/- 7 to 23 +/- 6 mm Hg (p less than .05). The time constant of isovolumetric pressure decay was calculated in three different ways, but none of these measurements was influenced by verapamil. Time of isovolumetric relaxation, duration of rapid ventricular filling, and peak rate of left ventricular lengthening were not significantly influenced by verapamil and remained highly abnormal. In contrast, peak rate of left ventricular posterior wall thinning declined further after verapamil from 2.9 +/- 1.2 to 2.4 +/- 1.4 1/sec (p less than .05).(ABSTRACT TRUNCATED AT 250 WORDS)

Asymetric septal hypertrophy (ASH): echocardiographic manifestations (Doctoral Thesis)

1978-06-07T00:00:00Z

In the late fifties and early sixties a distinct clinical entity has been recognized in clinical, hemodynamic and angiocardiographic studies. Since then a burst of information concerning this "cardiomyopathic" disorder has been forthcoming. In this chapter most available information is condensed in a systematic fashion, as an introduction to the thesis itself. Although various terms are currently still used to describe this condition, on clinical and hemodynamic grounds asymmetric septal hypertrophy, is considered in this study to be the common denominator and consequently this terminology is followed as a descriptor of the syndrome under discussion. The earliest report available is from Dittrich, who, in 1852, described in a necropsy study a patient with typical asymmetric septal hypertrophy. "Das Septum ventriculorum fast 1.5 - Zoll dick und von der Basis an unter den Aortaklappen bis zur Herzspitze herab mit dick gedri:ingten Muskelsubstanz durchsetzt,. Dilg2 in 1883 reviewed 15 similar cases, five of these are now recognisable as muscular septal hypertrophy. This author also noted that disease of the left ventricular outflow tract could coexist with other congenital abnormalities.