Geleijnse, M.L.

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.

Feasibility and Observer Reproducibility of Speckle Tracking Echocardiography in Congenital Heart Disease Patients (Article)

2013-03-19T00:00:00Z

Aims: The twisting motion of the heart has an important role in the function of the left ventricle. Speckle tracking echocardiography is able to quantify left ventricular (LV) rotation and twist. So far this new technique has not been used in congenital heart disease patients. The aim of our study was to investigate the feasibility and the intra- and inter-observer reproducibility of LV rotation parameters in adult patients with congenital heart disease. Methods and Results: The study population consisted of 66 consecutive patients seen in the outpatient clinic (67% male, mean age 31 ± 7.7 years, NYHA class 1 ± 0.3) with a variety of congenital heart disease. First, feasibility was assessed in all patients. Intra- and inter-observer reproducibility was assessed for the patients in which speckle tracking echocardiography was feasible. Adequate image quality, for performing speckle echocardiography, was found in 80% of patients. The bias for the intra-observer reproducibility of the LV twist was 0.0°, with 95% limits of agreement of -2.5° and 2.5° and for interobserver reproducibility the bias was 0.0°, with 95% limits of agreement of -3.0° and 3.0°. Intra- and inter-observer measurements showed a strong correlation (0.86 and 0.79, respectively). Also a good repeatability was seen. The mean time to complete full analysis per subject for the first and second measurement was 9 and 5 minutes, respectively. Conclusion: Speckle tracking echocardiography is feasible in 80% of adult patients with congenital heart disease and shows excellent intra- and inter-observer reproducibility.

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.

Normal left ventricular twist in patients with non-compaction cardiomyopathy, or in normal subjects with hypertrabeculation? (Article)

2012-09-01T00:00:00Z

The duration of the use of imatinib mesylate is only weakly related to elevated BNP levels in chronic myeloid leukaemia patients (Article)

2011-09-01T00:00:00Z

Cardiotoxicity has been feared as a potential side effect of imatinib therapy. Studies with short-term follow-up failed to identify an excess of cardiac events, but longer-term observations are needed to more definitely exclude this adverse effect. This study was designed to assess the cardiac effects of imatinib in patients under long-term treatment. We included 90 chronic myeloid leukaemia (CML) patients under imatinib therapy for a median treatment time of 3.3years (mean age 48.9±15.1years). Patients underwent clinical evaluation, electrocardiography, echocardiography (two-dimensional, colour flow, tissue Doppler and strain imaging), brain natiuretic peptide (BNP) and troponin I measurements. Twenty healthy volunteers were included as a control group for strain measurements. The mean ejection fraction was 68±7% and the median BNP level was 9.6pg/ml (interquartile range [IQR] 5.7-17.0pg/ml). Two patients had either an elevated BNP or a depressed ejection fraction (2.2%; 90%CI 0.9-6.8%). Most of troponin I measurements were lower than the detection limit, except for two patients. Longitudinal strain was similar to measurements in healthy controls. A weak relation was observed between log BNP and imatinib treatment duration and dose. There was no relation between these variables and left ventricle ejection fraction. In conclusion, matinib-related cardiotoxicity is an uncommon event in CML patients, even during long-term treatment. Therefore, its use should not be cause of great concern, and the usefulness of regular cardiac monitoring all patients while on imatinib therapy is questionable.

Indications and outcome of implantable cardioverter-defibrillators for primary and secondary prophylaxis in patients with noncompaction cardiomyopathy (Article)

2011-08-01T00:00:00Z

Prophylactic ICDs for Noncompaction Cardiomyopathy. Background: Noncompaction cardiomyopathy (NCCM) is a rare, primary cardiomyopathy, with initial presentation of heart failure, emboli, or arrhythmias, including sudden cardiac death. Implantable cardioverter-defibrillators (ICDs) are frequently used for primary and secondary prevention in different cardiomyopathy patients, but data about ICD in NCCM are scarce. The aim of this study was, therefore, to investigate ICD indications and outcomes in NCCM patients. Methods and Results: We collected prospective data from our NCCM cohort (n = 77 pts, mean age: 40 ± 14 years). ICD was implanted in 44 (57%) patients with NCCM according to the current ICD guidelines for nonischemic cardiomyopathies: in 12 for secondary prevention (7 × ventricular fibrillation, 5 × sustained ventricular tachycardia [VT]) and in 32 patients for primary prevention (heart failure/severe LV dysfunction). During a mean follow-up of 33 ± 24 months, 8 patients presented with appropriate ICD shocks due to sustained VT after median 6.1 [1-16] months. This included 4 of 32 (13%) patients in the primary prevention group and 4 of 12 (33%) in the secondary prevention group (P = 0.04). 9 patients presented with inappropriate ICD therapy: 6 (19%) in the primary and 3 (25%) in the secondary prevention group, at a median follow-up of 4 (2-23) months. Conclusions: In our cohort of NCCM patients, an ICD was frequently implanted for primary or secondary prevention of sudden cardiac death. At follow-up, frequent appropriate ICD therapy was observed in both groups, supporting the application of current ICD guidelines for primary and secondary prevention of sudden cardiac death in NCCM.

Transaortic flow velocity from dual-source MDCT for the diagnosis of aortic stenosis severity (Article)

2011-07-01T00:00:00Z

Objectives: To describe a method for the estimation of transaortic flow from multidetector computer tomography (MDCT). Background: Cardiac MDCT may not allow instantaneous flow measurement yet the components of flow, namely, volume change over time and lumenal area are recorded. Methods: In 36 patients, the transaortic flow velocity was determined on transthoracic echocardiography and also with cardiac MDCT as follows: On MDCT an axial orientation through the aortic root was obtained so that the nadir of all three aortic leaflets could be seen simultaneously in one axial image. Aortic valve area (AVA) was determined by planimetry and left ventricular volumes by endocardial border mapping at every 5% increment of the RR intervals. Flow velocity was then calculated as the incremental ejection volume Ã· duration of the increment Ã· AVA. Results: The transthoracic echocardiography (TTE) peak velocity and MDCT peak velocity were highly correlated (r = 0.75, P < 0.01). Transaortic peak velocity was higher when measured by MDCT as compared to TTE, with respectively a median [IQ-range] of 4.5 [2.9-5.3] and 4.0 [3.0-4.6], P < 0.01. For the diagnosis of severe aortic stenosis greater concordance with TTE peak velocity was seen with MDCT peak velocity (sensitivity 100%, specificity 76%) than with MDCT AVA (sensitivity 74%, specificity 76%). Conclusions: We show for the first time that transaortic flow velocity can be estimated by dual-source MDCT and has a better sensitivity for the detection of severe aortic stenosis than AVA planimetry when compared to the gold standard of TTE peak flow velocity. Copyright

Effect of experience on results of transcatheter aortic valve implantation using a medtronic CoreValve system (Article)

2011-06-15T00:00:00Z

Outcome after transcatheter aortic valve implantation (TAVI) depends on the patient risk profile, operator experience, progress in technology, and technique. We sought to compare the results of TAVI during the initiation phase and after certification to perform TAVI with the Medtronic CoreValve System without proctoring. A total of 165 consecutive patients was categorized into a first cohort of 33 patients treated before certification (November 2005 to December 2007) and a second cohort of 132 patients treated after certification (January 2008 to October 2010). The study end points were selected and defined according to the Valve Academic Research Consortium recommendations. Compared to cohort 2, the patients in cohort 1 more frequently had New York Heart Association class IIIIV (100% vs 71%, p <0.001), hypertension (67% vs 39%, p = 0.004), and aortic regurgitation grade IIIIV (46% vs 22%, p = 0.006) before TAVI. Over time, the patients in cohort 2 more frequently underwent a truly percutaneous approach (98% vs 82%, p = 0.002) without circulatory support (96% vs 67%, p <0.001) but with more concomitant percutaneous coronary intervention (11% vs 0%, p = 0.042) than the patients in cohort 1. They also more often received a 29-mm prosthesis (72% vs 24%, p <0.001), required less postimplantation balloon dilation (10% vs 27%, p = 0.008), and had less aortic regurgitation grade IIIIV after TAVI (12% vs 30%, p = 0.010). The clinical outcome showed a nonsignificant reduction in the combined safety end point (30% to 17%) but a significant reduction in cerebrovascular events (21% to 7%, p = 0.020) and life-threatening bleeding (15% to 5%, p = 0.044) in cohort 2. However, the reduction in overall bleeding and vascular complications (25% and 14%, respectively) was not significant. In conclusion, TAVI became significantly less complex and was associated with better results over time but remained associated with a high frequency of periprocedural major cardiovascular complications. Crown Copyright

Automated analysis of three-dimensional stress echocardiography (Article)

2011-06-01T00:00:00Z

Real-time three-dimensional (3D) ultrasound imaging has been proposed as an alternative for two-dimensional stress echocardiography for assessing myocardial dysfunction and underlying coronary artery disease. Analysis of 3D stress echocardiography is no simple task and requires considerable expertise. In this paper, we propose methods for automated analysis, which may provide a more objective and accurate diagnosis. Expert knowledge is incorporated via statistical modelling of patient data. Methods for identifying anatomical views, detecting endocardial borders, and classification of wall motion are described and shown to provide favourable results. We also present software developed especially for analysis of 3D stress echocardiography in clinical practice. Interobserver agreement in wall motion scoring is better using the dedicated software (96%) than commercially available software not dedicated for this purpose (79%). The developed tools may provide useful quantitative and objective parameters to assist the clinical expert in the diagnosis of left ventricular function.

Test-retest variability of volumetric right ventricular measurements using real-time three-dimensional echocardiography (Article)

2011-06-01T00:00:00Z

Background: Substantial variability in sequential echocardiographic right ventricular (RV) quantification may exist. Interobserver and intraobserver values are well known, but acquisition (test-retest) variability has been rarely assessed. The objective of this study was to determine the test-retest variability of sequential RV volume and ejection fraction (EF) measurements by real-time three-dimensional echocardiography in patients with congenital heart disease and healthy controls. Methods: Twenty-eight participants (21 patients with congenital heart disease, seven healthy controls; mean age, 30 ± 14 years; 43% men) underwent a series of three echocardiographic studies. To obtain interobserver and intraobserver test-retest variability, two sonographers acquired sequential RV data sets in each participant during one outpatient visit. RV volumetric quantification was done using semiautomated three-dimensional border detection. The variability data were analyzed using correlation coefficients, Bland-Altman analysis, and coefficients of variation. Results: Absolute mean differences for sequential intraobserver acquisitions were 12 ± 12 mL for end-diastolic volume, 7 ± 6 mL for end-systolic volume, and 4 ± 3% for EF. Interobserver and intraobserver test-retest variability, respectively, were 7% and 7% for RV end-diastolic volume, 14% and 7% for end-systolic volume, and 8% and 6% for EF. Conclusions: Good test-retest variability, besides the practical nature of real-time three-dimensional echocardiography for RV volume and EF assessment, makes it a valuable technique for serial follow-up. Although it may be challenging to diminish all factors that can influence echocardiographic examination for serial follow-up, standardization of RV size and functional measurements should be a goal to produce more interchangeable data. Copyright 2011 by the American Society of Echocardiography.

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.

Assessment of the aortic annulus by multislice computed tomography, contrast aortography, and trans-thoracic echocardiography in patients referred for transcatheter aortic valve implantation (Article)

2011-05-01T00:00:00Z

Objective: We sought to determine the level of agreement and the reproducibility of trans-thoracic echocardiography (TTE), contrast aortography (CA) and multislice computed tomography (MSCT) for the assessment of the aortic annulus, in patients referred for Transcatheter Aortic Valve Implantation (TAVI). Background: Correct measurement of the aortic annulus is important for TAVI. Methods: The dimensions of the aortic annulus were measured using TTE, CA and MSCT in 70 patients with severe aortic stenosis, referred for TAVI. Agreement between imaging techniques and interobserver variability was assessed using the Bland - Altman method and a linear regression model. Results: The MSCT Coronal view provided the largest mean annulus diameter (26.3 mm) followed by CA (24.4 mm), MSCT Mean (23.7 mm), TTE (22.6 mm), and MSCT Sagittal (21.8 mm) view. Differences in the annulus measurements were significant: MSCT Coronal view versus CA (mean, 95% confidence interval, Pearson's correlation) 2.0 mm, -1.9 to 6.0 mm, r = 0.72, CA versus MSCT Mean 0.2 mm, -3.3 to 3.7 mm, r = 0.76, MSCT Mean versus TTE 1.3 mm, -2.9 to 5.5 mm, r = 0.61, TTE versus MSCT Sagittal view 0.9 mm, -3.6 to 5.4 mm, r = 0.59, CA versus TTE 1.5 mm, -3.0 to 5.9 mm, r = 0.57. Interobserver variability was: TTE (mean, 95% confidence interval, Pearson's correlation) 0.29 mm, -4.2 to 4.8 mm, r = 0.57, CA 0.14 mm, -3.5 to 3.8 mm, r = 0.77, MSCT Mean 0.20 mm, -1.4 to 1.8 mm, r = 0.95. Conclusions: We found significant differences in the dimensions of the aortic annulus measured by MSCT, CA, and TTE. Interobserver variability for TTE and CA was substantially higher compared with MSCT.

Left ventricular mass regression one year after transcatheter aortic valve implantation (Article)

2011-03-01T00:00:00Z

Background: Left ventricular (LV) hypertrophy is associated with LV diastolic dysfunction and constitutes a risk factor for cardiac morbidity and mortality. The objective of this study was to investigate the degree of LV mass regression and the changes of LV diastolic function one year after transcatheter aortic valve implantation (TAVI). Methods Echocardiography was performed at baseline, before discharge, and at one-year follow-up in 63 consecutive patients with severe aortic stenosis who underwent TAVI with the Medtronic CoreValve System (Medtronic Inc, Minneapolis, MN). The LV mass was calculated using the Devereux formula and indexed to body surface area. Results One-year all-cause mortality was 29%. The LV mass index decreased from 126 ± 42 g/m2at baseline to 110 ± 30 g/m2at one-year follow-up (p < 0.001). Left ventricular ejection fraction and LV diastolic function did not change significantly. Mean transaortic gradient decreased from 47 ± 19 mm Hg at baseline to 9 ± 5 mm Hg at discharge and 9 ± 4 mm Hg at one year (p < 0.001), and was accompanied by significant clinical improvement. More than mild paravalvular aortic regurgitation was found in 24% and 15% of patients at discharge and one-year follow-up, respectively. Conclusions A significant regression in LV mass was found one year after TAVI. However, regression was incomplete and was not accompanied by an improvement in LV diastolic function.

The use of imatinib mesylate has no adverse effects on the heart function. Results of a pilot study in patients with chronic myeloid leukemia (Article)

2011-03-01T00:00:00Z

To investigate cardiac effects of imatinib at an extended follow-up (median 12.4 months), 12 chronic myeloid leukemia patients underwent cardiac screening. No significant changes on the frequency of cardiovascular signs and symptoms, electrocardiographic abnormalities, echocardiographic measurements and BNP levels were observed. Median ejection fraction was 67% at baseline versus 68% at follow-up (median intra-patient change 0.5%). Median BNP levels were 8.3 versus 7.3. pg/mL (median intra-patient change 0.2. pg/mL). Troponin I measures were below the lower limit of detection, whereas strain measures were similar to healthy control. This pilot study suggests that it is probably safe to perform cardiac monitoring on an annual basis.

The prognosis of implantable defibrillator patients treated with cardiac resynchronization therapy: Comorbidity burden as predictor of mortality (Article)

2011-01-01T00:00:00Z

AimsComorbidity, such as myocardial infarction, diabetes, and renal failure, plays a pivotal role in the prognosis of a patient with arrhythmias. However, data on the prognostic impact of comorbiditiy in heart failure patients with cardiac resynchronization therapy and defibrillation (CRT-D) are scarce. The purpose of this study was to determine the impact of comorbidity on survival in CRT-D patients.Methods and resultsThe study population consisted of 463 heart failure patients who received a CRT-D between 1999 and 2008 in Rotterdam and Basel. The Charlson comorbidity index (CCI) is often used as an adjusting variable in prognostic models. The Cox proportional hazards analysis was performed to determine the independent effect of comorbidity on survival. During a median follow-up of 30.5 months, 85 patients died. Mortality rates at 1 and 7 years were 6.3 and 32.3. Cumulative incidence of implantable cardioverter defibrillator (ICD) therapy at 7 years was 50, and death without ICD therapy was observed in 9 of patients. At least three comorbid conditions were observed in 81 of patients. Patients who died had a higher CCI score compared with those who survived (3.9 ± 1.5 vs. 2.9 ± 1.5; P < 0.001). An age-adjusted CCI score <5 was a predictor of mortality (hazard ratio 3.69, 95 CI 2.066.60; P < 0.001) independent from indication for ICD therapy, and from ICD interventions during the clinical course.ConclusionComorbidity is often present in heart failure patients, and a high comorbidity burden was a significant predictor of mortality in CRT-D recipients. Comorbidity cannot predict appropriate ICD therapy. Death without prior ICD therapy occurs in a minor proportion of patients. Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2010. For permissions please email: journals.permissionsoxfordjournals.org.2010The online version of this article has been published under an open access model. Users are entitled to use, reproduce, disseminate, or display the open access version of this article for non-commercial purposes provided that the original authorship is properly and fully attributed; the Journal, Learned Society and Oxford University Press are attributed as the original place of publication with correct citation details given; if an article is subsequently reproduced or disseminated not in its entirety but only in part or as a derivative work this must be clearly indicated. For commercial re-use, please contact journals. permissionsoxfordjournals.org. © Published on behalf of the European Society of Cardiology. All rights reserved.

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.

Usefulness of real-time three-dimensional echocardiography to identify right ventricular dysfunction in patients with congenital heart disease (Article)

2010-09-15T00:00:00Z

Because right ventricular (RV) dysfunction predicts a poor outcome in patients with congenital heart disease (CHD), regular monitoring of RV function is indicated. To date, cardiac magnetic resonance (CMR) imaging has been the reference method. A more practical, more accessible, and accurate tool would be preferred. We defined normality regarding RV systolic function using healthy controls and tested the ability of real-time 3-dimensional echocardiographic (RT3DE) findings to identify patients with CHD with RV dysfunction. The cutoff values for the RV volumes and ejection fraction (EF) were derived from the CMR imaging findings from 41 healthy controls (mean age 27 ± 8 years, 56% men). In 100 patients with varying CHDs (mean age 27 ± 11 years, 65% men), both RT3DE data sets (iE33) and short-axis CMR imaging (1.5 T) were obtained within 2 hours. The RT3DE and CMR RV volumes and EF were calculated using commercially available software. Receiver operating characteristic curves were created to obtain the sensitivity and specificity of the RT3DE data to identify RV dysfunction. Applying the cutoff values derived from the healthy controls using the CMR data of patients with CHD, we identified 23 patients with an enlarged indexed end-diastolic volume, 29 patients with an enlarged indexed end-systolic volume, and 21 patients with an impaired RVEF. The best cutoff values predicting RV dysfunction using the RT3DE findings were identified (indexed end-diastolic volume >105 ml/m2, indexed end-systolic volume >54 ml/m2, and EF <43%). The RT3DE findings revealed 23 patients with impaired RVEF, with 95% sensitivity, 89% specificity, and a negative predictive value of 99%. In conclusion, real-time 3-dimensional echocardiography is a very sensitive tool to identify RV dysfunction in patients with CHD and could be applied clinically to rule out RV dysfunction or to indicate additional quantitative analysis of RV function.

Anatomy of the mitral valvular complex and its implications for transcatheter interventions for mitral regurgitation (Article)

2010-08-17T00:00:00Z

Mitral regurgitation (MR) poses a significant clinical burden in the adult population, which is expected to increase even more with the ever prolonging life expectancies in developed countries. New technology has brought MR, once exclusively the arena of cardiac surgeons, to the attention of interventional cardiologists. A variety of device-oriented transcatheter strategies have evolved in recent years. A comprehensive understanding of mitral valvular anatomy is crucial for the selection of patients, the implementation of devices, and further refinements of these transcatheter techniques if they are eventually to produce procedural and clinical success. The aim of this review is to elucidate the morphology of the mitral valvular complex, integrating key anatomical features into the developing transcatheter options for the treatment of MR.

Prosthesis-patient mismatch after transcatheter aortic valve implantation with the medtronic corevalve system in patients with aortic stenosis (Article)

2010-07-15T00:00:00Z

A prosthesispatient mismatch (PPM) is present when the prosthetic valve is too small in relation to the patient's body size. The purpose of the present study was to investigate the frequency of PPM after the implantation of the Medtronic CoreValve System, and its relation to the clinical outcome. The indexed effective orifice area (EOA) was measured in 74 patients with symptomatic severe aortic stenosis, who had undergone successful transcatheter aortic valve implantation with the Medtronic CoreValve System, at baseline and discharge. PPM was defined as severe (indexed EOA <0.65 cm2/m 2) or moderate (indexed EOA 0.65 to 0.85 cm2/m 2). The indexed EOA increased from 0.35 ± 0.13 to 0.97 ± 0.34 cm2/m2 after transcatheter aortic valve implantation (p <0.001) and was accompanied by significant clinical improvement. Severe and moderate PPMs were found in 16% and 23% of patients, respectively. Patients with severe PPM were more symptomatic and had a smaller indexed EOA at baseline than those with moderate or no PPM (0.28 ± 0.09 vs 0.36 ± 0.12 cm2/m2, p <0.05). Functional status and mortality at 30 days and 6 months was not significantly different between the patients with severe PPM and those with moderate or no PPM. In conclusion, the indexed EOA increased significantly after transcatheter aortic valve implantation. Severe PPM was observed in 16% of the patients and was not associated with the clinical outcome.

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

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.

Clinical Value of Real-Time Three-Dimensional Echocardiography for Right Ventricular Quantification in Congenital Heart Disease: Validation With Cardiac Magnetic Resonance Imaging (Article)

2010-02-01T00:00:00Z

Background: The objective of this study was to test the feasibility, accuracy, and reproducibility of the assessment of right ventricular (RV) volumes and ejection fraction (EF) using real-time three-dimensional echocardiographic (RT3DE) imaging in patients with congenital heart disease (CHD), using cardiac magnetic resonance (CMR) as a reference. Methods: RT3DE data sets and short-axis cine CMR images were obtained in 62 consecutive patients (mean age, 26.9 ± 10.4 years; 65% men) with various CHDs. RV volumetric quantification was done using semiautomated 3-dimensional border detection for RT3DE images and manual tracing of contours in multiple slices for CMR images. Results: Adequate RV RT3DE data sets could be analyzed in 50 of 62 patients (81%). The time needed for RV acquisition and analysis was less for RT3DE imaging than for CMR (P < .001). Compared with CMR, RT3DE imaging underestimated RV end-diastolic and end-systolic volumes and EF by 34 ± 65 mL, 11 ± 55 mL, and 4 ± 13% (P < .05) with 95% limits of agreement of ±131 mL, ±109 mL, and ±27%, as shown by Bland-Altman analyses, with highly significant correlations (r = 0.93, r = 0.91, and r = 0.74, respectively, P < .001). Interobserver variability was 1 ± 15%, 6 ± 17%, and 8 ± 13% for end-diastolic and end-systolic volumes and EF, respectively. Conclusion: In the majority of unselected patients with complex CHD, RT3DE imaging provides a fast and reproducible assessment of RV volumes and EF with fair to good accuracy compared with CMR reference data when using current commercially available hardware and software. Further studies are warranted to confirm our data in similar and other patient populations to establish its use in clinical practice.

Frequency of Conduction Abnormalities After Transcatheter Aortic Valve Implantation With the Medtronic-CoreValve and the Effect on Left Ventricular Ejection Fraction (Article)

2010-01-01T00:00:00Z

New conduction abnormalities occur frequently after transcatheter aortic valve implantation (TAVI). The relation between new conduction disorders and left ventricular (LV) systolic function after TAVI is unknown. The purpose of the present prospective, single-center study was to investigate the effect of TAVI on LV systolic function in relation to TAVI-induced conduction abnormalities. A total of 27 patients had undergone electrocardiography and transthoracic echocardiography the day before and 6 days after TAVI with the Medtronic-CoreValve system. The LV ejection fraction (EF) was calculated using the biplane Simpson method. The systolic mitral annular velocities and longitudinal strain were measured using speckle tracking echocardiography. After TAVI, 18 patients (67%) had new conduction abnormalities; 4 (15%) had a new paced rhythm and 14 patients (52%) had new left bundle branch block. In the patients with new conduction abnormalities, the EF decreased from 47 ± 12% to 44 ± 10%. In contrast, in those without new conduction abnormalities, the EF increased from 49 ± 12% to 54% ± 12%. The change in EF was significantly different among those with and without new conduction abnormalities (p <0.05). In patients without new conduction abnormalities, an improvement was found in the systolic mitral annular velocities and longitudinal strain (p <0.05). In contrast, in patients with new conduction abnormalities, the changes were not significant. In conclusion, the induction of new conduction abnormalities after TAVI with the Medtronic-CoreValve was associated with a lack of improvement in LV systolic function.

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.

Left ventricular remodelling and systolic function measurement with 64 multi-slice computed tomography versus second harmonic echocardiography in patients with coronary artery disease: A double blind study (Article)

2010-01-01T00:00:00Z

The present study evaluated LV volumes, ejection fraction (LVEF) and stroke volume (SV) obtained by 64-MDCT and to compare these data with those obtained by second harmonic 2D Echo, in patients referred for non-invasive coronary vessels evaluation. The most common technique in daily clinical practice used for determination of LV function is two-dimensional echocardiography (2D-TTE). Multi-detector computed tomography (MDCT) is an emerging new technique to detect coronary artery disease (CAD) and was recently proposed to assess LV function. 93 patients underwent to 64-MDCT for LV function and volumes assessment by segmental reconstruction algorithm (Argus) and compared with recent (2 months) 2D-TTE, all images were processed and interpreted by two observers blinded to the Echo and MDCT results. A close correlation between TTE and 64 MDCT was demonstrated for the ejection fraction LVEF (r = 0.84), end-diastolic volume LVEDV (r = 0.80) and end-systolic volume LVESV (r = 0.85); acceptable correlation was recruited for stroke volume LVSV (r = 0.58). Optimal results were recruited for inter-observer variability for 64-MDCT measured in 45 patients: LVESV (r = 0.82, p < 0.001), LVEDV (r = 0.83, p < 0.001), LVEF (r = 0.69, p < 0.002) and SV (r = 0.66, p < 0.001). Our results, showed that functional and temporal information contained in a coronary 64-MDCT study can be used to assess left ventricular (LV) systolic function and LV dimensions with good reproducibility and acceptable correlation respect to 2D-TTE. The combination of non-invasive coronary artery imaging and assessment of global LV function might became in the future a fast and conclusive cardiac work-up in patients with CAD.

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

Changes in mitral regurgitation after transcatheter aortic valve implantation (Article)

2010-01-01T00:00:00Z

Objectives: To assess the acute and intermediate changes in mitral regurgitation (MR) severity after transcatheter aortic valve implantation (TAVI) with the CoreValve Revalving SystemTM (CRS). Background: Following surgical aortic valve replacement, improvement in MR is reported in 27-82% of the patients. The changes in MR severity following CRS implantation are unknown. Methods: Transthoracic echocardiography was performed in 79 consecutive patients before and after treatment, and at the first outpatient visit. Left ventricular dimensions and ejection fraction (LVEF), left atrial (LA) size, and aortic gradient were measured. MR was assessed by color flow mapping and was graded as none, mild, moderate, or severe. It was defined as organic or functional. The depth of CRS implantation was measured by angiography. Results: Post-treatment, the mean gradient decreased from 48 ± 16 mm Hg to 9 ± 5 mm Hg (P < 0.0001). There was no significant change in the left ventricular dimensions, LA size, and LVEF. MR pretreatment was mild, moderate, or severe in 57%, 18%, and 1% of the patients, respectively. It was defined as organic in 27 patients (36%) and functional in 27 patients (36%). The degree of MR remained unchanged in 61% of the patients, improved in 17%, and worsened in 22%. MR improvement was associated with a lower baseline LVEF (P = 0.02). There was no association between the changes in MR severity and the depth of CRS implantation. Conclusions: Most patients who underwent TAVI had some degree of MR. Overall there was no change in the degree of MR post-treatment. Patients in whom MR improved had a lower LVEF at baseline.

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.

Response to letter to editor by Jastrzebski 'Short PR interval in Pompe disease' (Article)

2009-12-01T00:00:00Z

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.

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.

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.

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

2009-04-01T00:00:00Z

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

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

2009-04-01T00:00:00Z

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

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

2009-03-01T00:00:00Z

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

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.

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

2009-02-01T00:00:00Z

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

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

2009-01-01T00:00:00Z

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

Let's twist (Article)

2009-01-01T00:00:00Z

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.

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

2008-12-15T00:00:00Z

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

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.

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

2008-11-01T00:00:00Z

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

Cardiac involvement in adults with Pompe disease (Article)

2008-10-01T00:00:00Z

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

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

2008-10-01T00:00:00Z

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

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

2008-09-15T00:00:00Z

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

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.

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.

Cardiac tamponade due to a ruptured aneurysm of the sinus of valsalva (Article)

2008-05-01T00:00:00Z

Background and Aim: A sinus of Valsalva aneurysm (SVA) is a rare cardiac anomaly. Rupture of a SVA often causes hemodynamic instability due to intracardiac shunting or cardiac tamponade, therefore immediate diagnosis and urgent treatment are required. Methods: We report an 18-year-old female with cardiac tamponade due to rupture of a localized aneurysm of the right coronary sinus of Valsalva. No other congenital or acquired cardiac anomalies were found. Neurological observation precluded urgent surgery with heparinization and extracorporeal circulation. Results: Semi-urgently the SVA was successfully resected. Conclusions: Semi-urgent surgery for a ruptured aneurysm of the Sinus of Valsalva was successful. In selected cases off pump surgery can be contemplated.

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

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.

Partial ventricular septal defect (Pacman® Heart) (Article)

2008-03-01T00:00:00Z

Complete ventricular septal defects (VSD) can be congenital (estimated prevalence 0.5% in live births) (Roguin N, et al. High prevalence of muscular ventricular septal defect in neonates. J Am Coll Cardiol 1995;26:1545-1548) or may be a complication of acute myocardial infarction (estimated incidence in the era of thrombolysis 0.2%) [Crenshaw BS, et al. Risk factors, angiographic patterns, and outcomes in patients with ventricular septal defect complicating acute myocardial infarction. GUSTO-I (Global Utilization of Streptokinase and TPA for Occluded Coronary Arteries) Trial Investigators. Circulation 2000;101:27-32]. In this paper, we report two unique cases of partial VSD.

Rapid and accurate measurement of LV mass by biplane real-time 3D echocardiography in patients with concentric LV hypertrophy: Comparison to CMR (Article)

2008-03-01T00:00:00Z

Aims: To evaluate the accuracy of real-time three-dimensional echocardiography (RT3DE) using a biplane and multiplane method in determining left ventricular (LV) mass compared to cardiac magnetic resonance imaging (CMR). Methods and results: LV mass was measured in 18 adult patients with congenital aortic stenosis using CMR and echocardiography (M-mode, two-dimensional echocardiography (2DE), and RT3DE). RT3DE data were analysed using a biplane and multiplane method. No geometric assumptions were necessary using the multiplane RT3DE method.With regard to biplane or multiplane RT3DE, no tendency of over- or underestimation of LV mass was observed. Pearson's correlation coefficients for RT3DE versus CMR were 0.84 and 0.90 for the biplane and multiplane method, respectively. In addition, the accuracy of both RT3DE methods were comparable (Fisher's R-to-Z transformation: Z = 0.69, P = NS). Finally, off-line analysis using biplane RT3DE was significantly faster than multiplane RT3DE (3.8 ± 1.2 vs. 7.8 ± 1.7 minutes, P < 0.001). Conclusions: Biplane RT3DE provided an accurate estimate of LV mass in patients with concentric left ventricular hypertrophy, which was not improved by multiplane RT3DE. The accuracy and speed of analysis renders biplane RT3DE an attractive tool in daily clinical practice for assessing the degree of LV hypertrophy.

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

2008-03-01T00:00:00Z

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

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

2008-01-11T00:00:00Z

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

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.

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.

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

2007-10-01T00:00:00Z

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

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

2007-10-01T00:00:00Z

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

2007-10-01T00:00:00Z

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

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.

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

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.

Noninvasive evaluation of ischaemic heart disease: myocardial perfusion imaging or stress echocardiography? (Article)

2003-05-01T00:00:00Z

Stress echocardiography and myocardial perfusion imaging are commonly used noninvasive imaging modalities for the evaluation of ischaemic heart disease. Both modalities have proved clinically useful in the entire spectrum of coronary artery disease. Both techniques can detect coronary artery disease and provide prognostic information. Both techniques can identify low-risk and high-risk subsets among patients with known or suspected coronary artery disease and thus guide patient management decisions. In patients with acute myocardial infarction, both techniques have been used to identify residual viable tissue and predict improvement of function over time. In patients with chronic ischaemic left ventricular (LV) dysfunction, viability assessment with either modality can be used to predict improvement of function after revascularisation and thus guide patient treatment.

Usefulness and limitations of dobutamine-atropine stress echocardiography for the diagnosis of coronary artery disease in patients with left bundle branch block. A multicentre study. (Article)

2000-10-30T00:00:00Z

BACKGROUND: Patients with left bundle branch block exhibit abnormal septal motion which may limit the interpretation of stress echocardiograms. This study sought to assess the diagnostic value of dobutamine-atropine stress echocardiography in left bundle branch block patients. METHODS AND RESULTS: Sixty-four left bundle branch block patients (mean age 59 years, 24 men) with suspected coronary artery disease underwent dobutamine-atropine stress echocardiography and coronary arteriography. Myocardial ischaemia was defined as new or worsening wall thickening abnormalities. Coronary artery disease was quantitatively defined as a diameter stenosis >/=50% in a major epicardial artery. Rest septal motion was normal (apart from the early systolic septal notch) in 34 patients (53%) and abnormal in 30 patients (47%). Rest septal thickening was normal in 32 patients (50%) and abnormal in 32 patients (50%). All seven patients with a QRS duration >/=160 ms and an abnormal QRS axis had abnormal rest septal motion and thickening. Inter-observer agreement for ischaemia was 88%. In all but one patient disagreement was in the septum. For the anterior and posterior circulation, respectively, sensitivity was 60% (9/15) and 67% (8/12), specificity was 94% (46/49) and 98% (51/52), and accuracy was 86% (55/64) and 92% (59/64). Sensitivity for the anterior circulation tended to be better in patients with normal rest septal thickening (83% vs 44%). CONCLUSIONS: Dobutamine-atropine stress echocardiography has excellent diagnostic specificity in left bundle branch block patients with suspected coronary artery disease. In patients with abnormal rest septal thickening, however, dobutamine-atropine stress echocardiography may lack good sensitivity for detection of coronary artery disease in the anterior circulation. Left bundle branch block patients who potentially most benefit from dobutamine-atropine stress echocardiography may initially be selected by their resting electrocardiogram.

Safety and prognostic value of early dobutamine-atropine stress echocardiography in patients with spontaneous chest pain and a non-diagnostic electrocardiogram. (Article)

2000-03-04T00:00:00Z

AIMS: To risk stratify and shorten hospital stay in patients with spontaneous (resting) chest pain and a non-diagnostic electrocardiogram (ECG). METHODS AND RESULTS: The study comprised 102 patients (mean age 58+/-12 years, 67 men) with spontaneous chest pain and a non-diagnostic ECG. Forty-three patients had suspected coronary artery disease and 59 had known (but of unknown actual significance) coronary artery disease. All patients underwent serial creatine kinase enzyme measurements, continuous ECG monitoring for at least 12 h and early dobutamine-atropine stress echocardiography in patients with negative creatine kinase enzymes and normal findings at ECG monitoring. Dobutamine-atropine stress echocardiography was considered positive in patients with new or worsening wall thickening abnormalities. Patients with negative dobutamine-atropine stress echocardiography were discharged after the test. In-hospital and 6 month follow-up events noted were cardiac death, non-fatal myocardial infarction, unstable angina, and coronary artery bypass surgery or angioplasty. Thirteen patients had evidence of evolving myocardial infarction by elevated creatine kinase enzymes, or unstable angina by ECG monitoring. In the remaining 89 patients, dobutamine-atropine stress echocardiography was performed after a median observation period of 31 h (range 12-68 h). During dobutamine-atropine stress echocardiography no serious complications (death, non-fatal myocardial infarction, sustained ventricular tachycardia or ventricular fibrillation) occurred. Dobutamine-atropine stress echocardiography results were of poor quality in three, non-diagnostic in six, negative in 44 and positive in 36 patients. In the 80 patients with diagnostic dobutamine-atropine stress echocardiography, variables associated with in-hospital events (n=7) were history of exertional angina (P<0. 005), chest pain score (P<0.005), stress-induced angina (P<0.001) and positive dobutamine-atropine stress echocardiography (P<0.005). Variables associated with follow-up events (n=11) were history of exertional angina (P<0.05), chest pain score (P<0.001), stress-induced angina (P<0.01) and positive dobutamine-atropine stress echocardiography (P<0.01). At multivariate analysis the only significant predictor of events was positive dobutamine-atropine stress echocardiography (P<0.01). CONCLUSION: Early dobutamine-atropine stress echocardiography may safely distinguish between low- and high-risk subsets for subsequent cardiac events in patients with spontaneous chest pain and a non-diagnostic ECG.

The grade of worsening of regional function during dobutamine stress echocardiography predicts the extent of myocardial perfusion abnormalities (Article)

2000-01-01T00:00:00Z

AIM: To evaluate the angiographic, myocardial perfusion, and wall motion abnormalities in patients with severe compared with mild worsening of regional function during dobutamine stress echocardiography (DSE) for evaluation of myocardial ischaemia. METHODS: 147 patients with significant coronary artery disease and new or worsening wall motion abnormalities during DSE were enrolled. Left ventricular function was evaluated using a 16 segment/4 grade score model where 1 = normal and 4 = dyskinesis. Simultaneous sestamibi SPECT myocardial perfusion imaging was performed in all patients. RESULTS: Severe worsening of regional function (an increase in wall motion score of two grades or more in >/= 1 segment) was detected in 37 patients, while 110 patients had mild worsening (an increase in wall motion score of no more than one grade in >/= 1 segment). Patients with severe worsening of regional function had more stenotic coronary arteries (2.31 (0.8) v 1.97 (0. 8) (mean (SD)) (p <0.05), a higher prevalence of left anterior descending coronary artery disease (95% v 73%) (p < 0.05), a higher resting wall motion score index (1.71 (0.42) v 1.51 (0.40) (p = 0. 01), and more stress perfusion defects (3.8 (1.5) v 2.8 (1.5) (p < 0.001) compared with patients with mild worsening. Multivariate analysis identified the number of stress perfusion defects (p < 0. 005, chi(2) = 8.8) and the number of ischaemic segments on echocardiography (p < 0.05, chi(2) = 4.3) as independent variables associated with severe worsening of regional function. CONCLUSIONS: The grade of worsening of regional function during DSE predicts the underlying extent of myocardial perfusion abnormalities. The occurrence of severe worsening of regional function is associated with variables known to predict worse prognosis in patients with coronary artery disease.

Dobutamine stress myocardial function versus nuclear perfusion imaging (Doctoral Thesis)

1999-06-23T00:00:00Z

Confirming or excluding coronary artery disease in patients with chest pain remains a challenge because this disease is still the leading cause of death in the Western world (I). Traditionally, exercise electrocardiography is perfomled as a first-line noninvasive diagnostic stress test (2). However, a substantial number of patients referred for evaluation of chest pain are unable to perform adequate exercise testing, mainly because of decollditioning or neurologic, respiratory, peripheral vascular, or orthopedic limitations (3). In these patients, dobutamine stress represents an alternative, exercise independent stress technique. Usually, this fann of stress is combined with two-dimensional echocardiography, providing functional data on myocardial wall thickening (4), or nuclear perfusion imaging, providing data on myocardial perfusion (5). Despite the increasing number of dobutamine tests performed each year, little is known about the relative diagnostic and prognostic value of the two imaging modalities. In this thesis, a comparison between dobutamine stress echocardiography and teclmetium-99m single-photon emission computed tomographic imaging is presented. Part A of the thesis deals with the methodology of dobutamine stress testing and the respective benefits of dobutamine stress echocardiography and technetium-99m perfusion imaging (chapters I to 3). In part B the diagnostic merits of the two stress modalities in patients with suspected coronary artery disease (chapter 4), prior myocardial infarction (chapter 5), left ventricular hypertrophy (chapter 6), and left bundle branch block (chapters 7 and 8) are discussed. Part C of the thesis discusses the prognostic merits of the stress modalities in patients with stable (chapters 9 to II) and suspected unstable chest pain syndromes (chapter 12).

Noninvasive diagnosis of coronary artery stenosis in women with limited exercise capacity: comparison of dobutamine stress echocardiography and 99mTc sestamibi single-photon emission CT (Article)

1998-01-01T00:00:00Z

OBJECTIVES: To compare the accuracy of dobutamine stress echocardiography (DSE) and simultaneous 99mTc sestamibi (MIBI) single-photon emission CT (SPECT) imaging for the diagnosis of coronary artery stenosis in women. PATIENTS: Seventy women with limited exercise capacity referred for evaluation of myocardial ischemia. METHODS: DSE (up to 40 microg/kg/min) was performed in conjunction with stress MIBI SPECT. Resting MIBI images were acquired 24 h after the stress test. Ischemia was defined as new or worsened wall motion abnormalities confirmed by DSE and as reversible perfusion defects confirmed by MIBI. Significant coronary artery disease was defined as > or = 50% luminal diameter stenosis. RESULTS: DSE was positive for ischemia in 35 of 45 patients with coronary artery stenosis and in 2 of 25 patients without coronary artery stenosis (sensitivity = 78% CI, 68 to 88; specificity = 92% CI, 85 to 99; and accuracy = 83% CI, 74 to 92). A positive MIBI study for ischemia occurred in 29 patients with coronary artery stenosis and in 7 patients without coronary artery stenosis (sensitivity = 64% CI, 53 to 76; specificity = 72% CI, 61 to 83; and accuracy = 67% CI, 56 to 78 [p < 0.05 vs DSE]). In the 59 vascular regions with coronary artery stenosis, the regional sensitivity of DSE was higher than MIBI (69% CI, 62 to 77 vs 51% CI, 42 to 59, p < 0.05), whereas specificity in the 81 vascular regions without significant stenosis was similar (89% CI, 84 to 94 vs 88% CI, 82 to 93, respectively). CONCLUSION: DSE is a useful noninvasive method for the diagnosis of coronary artery stenosis in women and provides a higher overall and regional diagnostic accuracy than dobutamine MIBI SPECT in this particular population.

Safety and feasibility of dobutamine-atropine stress echocardiography for the diagnosis of coronary artery disease in diabetic patients unable to perform an exercise stress test (Article)

1998-01-01T00:00:00Z

OBJECTIVE: Dobutamine stress testing is increasingly used for the diagnosis and functional evaluation of coronary artery disease. However, little is known about the safety and feasibility of this stress modality in diabetic patients. RESEARCH DESIGN AND METHODS: We studied the impact of diabetes on hemodynamic profile and on the safety and feasibility of dobutamine (up to 40 microg x kg(-1) x min(-1)) and atropine (up to 1 mg) stress echocardiography for the diagnosis of coronary artery disease in 1,446 consecutive patients (aged 60+/-12 years, 962 men) with limited exercise capacity and suspected myocardial ischemia. Of these, 184 patients were known to have IDDM or NIDDM. The test was considered feasible when 85% of the maximal heart rate and/or an ischemic end point (new or worsened wall motion abnormalities, ST segment depression, or angina) was achieved. RESULTS: No myocardial infarction or death occurred during the test. There was no significant difference between diabetic and nondiabetic patients with regard to heart rate increase during dobutamine stress echocardiography (58+/-25 vs. 61+/-24 beats/min), peak rate pressure product (18,400+/-3,135 vs. 18,048+/-4454), or the prevalence of hypotension (systolic blood pressure drop of >40 mmHg) (7 vs. 5%), ventricular tachycardia (5.4 vs. 4.5%), and supraventricular tachycardia (3 vs. 4%) during the test. Dobutamine stress echocardiography was feasible in 92% of the diabetic patients and in 90% of the nondiabetic patients. Coronary angiography was performed in 55 diabetic and 240 nondiabetic patients. Sensitivity, specificity, and accuracy of dobutamine stress echocardiography for the diagnosis of coronary artery disease in diabetic patients were 81, 85, and 82%. Those in nondiabetic patients were 74, 87, and 77%, respectively (NS). CONCLUSIONS: Dobutamine stress echocardiography is a feasible method for the diagnosis of coronary artery disease in patients with limited exercise capacity with a comparable safety, feasibility, and accuracy in diabetic and nondiabetic patients.

Relation between ST segment elevation during dobutamine stress test and myocardial viability after a recent myocardial infarction (Article)

1997-01-01T00:00:00Z

OBJECTIVE: To assess the relation between ST segment elevation during the dobutamine stress test and late improvement of function after acute Q wave myocardial infarction. PATIENTS AND DESIGN: 70 patients were studied a mean (SD) 8 (3) days after acute myocardial infarction with high dose dobutamine-atropine stress echocardiography and a follow up echocardiogram at 85 (10) days. A score model based on 16 segments and four grades was used to assess left ventricular function. Functional improvement was defined as a reduction of wall motion score > or = 1 in > or = 1 segments at follow up. INTERVENTION: Myocardial revascularisation was performed in 23 patients (33%) before follow up studies. RESULTS: ST segment elevation occurred in 40 patients (57%). Late functional improvement occurred in 35 patients (50%). Functional improvement was more common in patients with ST segment elevation (68% v 30%, P < 0.005) and they had a higher mean (SD) number of improved segments at follow up (1.9 (2.2) v 0.5 (1.1), P < 0.005). The wall motion score index decreased between baseline and follow up in patients with ST segment elevation (1.54 (0.50) v 1.48 (0.43), P < 0.05) but not in patients without ST segment elevation (1.39 (0.60) v 1.45 (0.47)). The accuracy of ST segment elevation for the prediction of functional improvement was similar to that of low dose dobutamine echocardiography in patients with anterior infarction (80% v 83%) and in patients who underwent revascularisation (78% v 83% respectively). CONCLUSION: In patients with a recent Q wave myocardial infarction, dobutamine-induced ST segment elevation is a valuable marker of myocardial viability particularly when the test is performed without or with suboptimal echocardiographic imaging.