A.C. Van Rossum

Reliability of left ventricular volumes and function measurements using three-dimensional speckle tracking echocardiography

AIMS Although the accuracy of three-dimensional speckle tracking echocardiography (STE) to quantify left ventricular (LV) volumes and function has been demonstrated, its reliability has not been studied in great detail. The aim of the study was to determine inter-observer, intra-observer, and test-retest reliability of echocardiographic measurements of LV volumes and function using three-dimensional STE. METHODS AND RESULTS A total of 140 consecutive patients presenting for routine echocardiographic examination underwent three-dimensional STE. Twenty-three of the 140 patients (16%) were excluded from the analysis due to atrial fibrillation or insufficient image quality. In the remaining 117 patients [69 males, age 59 ± 16 years, ejection fraction (EF) 51 ± 13%], intra-observer and inter-observer reliability of LV volumes, EF, and global and segmental strain measurements was determined, whereas test-retest reliability was assessed in a subgroup of 50 patients. LV volumes and EF measurements demonstrated good reliability [intraclass correlation coefficient (ICC): 0.85-0.99; standard error of measurement (SEM): 3.1-9.2 mL and 1.7-4.0%, respectively]. Reliability of global circumferential strain measurements (ICC: 0.85-0.97; SEM: 1.4-2.6%) was superior to longitudinal (ICC: 0.66-0.92; SEM: 1.0-2.1%) and radial strain measurements (ICC: 0.52-0.88; SEM: 4.4-8.1%), with similar results found for segmental strain measurements (P < 0.001 for all). Reliability was not significantly affected by the image quality or temporal resolution of 3D data sets for any parameter. CONCLUSION Good intra-observer, inter-observer, and test-retest reliability support the use of three-dimensional STE for routine evaluation of LV volumes and EF. Global and segmental circumferential strain measurements also demonstrate high reliability, whereas analysis by a single observer is currently recommended for longitudinal and radial strain due to limited inter-observer and test-retest reliability.

The Potential Role of Erythropoietin in Chronic Heart Failure: From the Correction of Anemia to Improved Perfusion and Reduced Apoptosis?

Besides stimulating erythropoiesis, erythropoietin (EPO) exerts powerful proangiogenic and antiapoptotic effects. These erythropoiesis-independent effects are potentially useful as a supplement for the treatment of chronic heart failure (CHF). EPO may improve microvascular capacity of ischemic myocardial tissue and could thereby (partially) restore myocardial function. In addition, EPO could protect cardiomyocytes from hypoxic damage and prevent them from apoptosis. However, the clinical value of these erythropoiesis-independent effects for the treatment of CHF remains to be elucidated. Small-sized trials evaluating the effects of EPO treatment on surrogate endpoints in patients with CHF showed positive effects in general; however, their mutual results are not always unambiguous. Moreover, increasing hematocrit levels with EPO has been associated with increased blood viscosity and an inherent risk of thromboembolic events. A currently running multicenter phase III trial is designed to provide clarity concerning the effects of EPO on outcome and safety in patients with CHF. Focusing primarily on outcome, however, does not provide insight into the mode of action and isolated benefits of the erythropoiesis-independent effects of EPO. Further exploration of these effects is a key issue to gain knowledge of the full potential of EPO for the treatment of CHF.

Progression in attenuating myocardial reperfusion injury: An overview

Reperfusion by means of percutaneous coronary intervention or thrombolytic therapy is the most effective treatment for acute myocardial infarction, markedly reducing mortality and morbidity. Reperfusion however induces necrotic and apoptotic damages to cardiomyocytes, that were viable prior to reperfusion, a process called lethal reperfusion injury. This process, consisting of many single processes, may be responsible of up to half of the final infarct size. A myriad of therapies as an adjunct to reperfusion have been studied with the purpose to attenuate reperfusion injury. The majority of these studies have been disappointing or contradicting, but recent proof-of-concept trials show that reperfusion injury still is a legitimate target. This overview will discuss these trials, the progression in attenuating myocardial reperfusion injury, promising therapies, and future perspectives.

Noninvasive identification of left-sided heart failure in a population suspected of pulmonary arterial hypertension

Exclusion of pulmonary hypertension secondary to left-sided heart disease (left heart failure (LHF)) is pivotal in the diagnosis of pulmonary arterial hypertension (PAH). In case of doubt, invasive measurements are recommended. The aim of the present study was to investigate whether it is possible to diagnose LHF using noninvasive parameters in a population suspected of PAH. 300 PAH and 80 LHF patients attended our pulmonary hypertension clinic before August 2010, and were used to build the predictive model. 79 PAH and 55 LHF patients attended our clinic from August 2010, and were used for prospective validation. A medical history of left heart disease, S deflection in V1 plus R deflection in V6 in millimetres on ECG, and left atrial dilation or left valvular heart disease that is worse than mild on echocardiography were independent predictors of LHF. The derived risk score system showed good predictive characteristics: R2=0.66 and area under the curve 0.93. In patients with a risk score ≥72, there is 100% certainty that the cause of pulmonary hypertension is LHF. Using this risk score system, the number of right heart catheterisations in LHF may be reduced by 20%. In a population referred under suspicion of PAH, a predictive model incorporating medical history, ECG and echocardiography data can diagnose LHF noninvasively in a substantial percentage of cases. A risk score system can identify left-heart failure as alternative PH cause in patients suspected of PAH clinically http://ow.ly/JAIkR

Safety of gadoversetamide in patients with acute and chronic myocardial infarction

To assess the safety data from two large, multicenter, phase 2 trials on the use of gadoversetamide (OptiMARK, Tyco Healthcare/Mallinckrodt, St. Louis, MO) as a contrast agent in delayed hyperenhancement magnetic resonance imaging (DE‐MRI) in patients with acute and chronic myocardial infarction (MI).

Incremental diagnostic value of epicardial adipose tissue for the detection of functionally relevant coronary artery disease

BACKGROUND AND AIM To determine the incremental diagnostic value of epicardial adipose tissue (EAT) volume in addition to the coronary artery calcium (CAC) score for detecting hemodynamic significant coronary artery disease (CAD). METHODS AND RESULTS 122 patients (mean age 61 ± 10 years, 61% male) without a previous cardiac history underwent a non-contrast CT scan for calcium scoring and EAT volume measurements. Subsequently all patients underwent invasive coronary angiography (ICA) in conjunction with fractional flow reserve (FFR) measurements. A stenosis >90% and/or a FFR ≤0.80 were considered significant. Mean EAT volume and CACscore were 128 ± 51 cm(3) and 418 ± 704, respectively. The correlation between EAT volume and the CACscore was poor (r = 0.11, p = 0.24). Male gender (odds ratio [OR] 2.86, p = 0.01), CACscore ([cut-off value 100] OR 3.31, p = 0.003, and EAT volume ([cut-off value 92 cm(3)] OR 4.28, p = 0.01) were associated with flow-limiting disease. The multivariate model revealed that only male gender (OR 2.50, p = 0.045), CAC score (OR 3.60, p = 0.005), and EAT volume (OR 4.95, p = 0.02) were independent predictors of myocardial ischemia. Using the cut-off values of 100 (CAC score) and 92 cm(3) (EAT volume), sensitivity, specificity, negative predictive value, positive predictive value, and accuracy for detecting functionally relevant CAD as indicated by FFR were 71, 57, 77, 50 and 63% and 91, 29, 85, 44 and 52% for the CACscore and EAT volume, respectively. Adding EAT volume to the CAC score and cardiovascular risk factors did not enhance diagnostic performance for the detection of significant CAD (p = 0.57). CONCLUSION EAT volume measurements have no diagnostic value beyond calcium scoring and cardiovascular risk factors in the detection of hemodynamic significant CAD.

Don't judge the myocardium by its cover : The incremental value of cardiac magnetic resonance imaging in left ventricular hypertrophy

A 51-year-old female presenting with fatigue demonstrated cardiac enlargement on her chest x-ray. The electrocardiogram was normal (Fig. 1). However, echocardiography suggested asymmetrical hypertrophic cardiomyopathy. Cardiac magnetic resonance (CMR) imaging was performed for further evaluation. The cine images showed a maximum wall thickness of 28mm at the mid anterolateral segment (Fig. 2a; Supplementary movie 1). Due to the atypical

703 Abnormal left ventricular rotational direction predicts acute response to cardiac resynchronization therapy

Background: Left ventricular (LV) torsion is an essential component of cardiac contraction in normal heart function, but is impaired in patients with dilated cardiomyopathy. The aim of this study is to determine the predictive value of impaired torsion for the acute response to cardiac resynchronization therapy (CRT) in these patients. Methods: In 35 CRT candidates and 12 controls, basal and apical LV rotations were calculated using MRI tagging. Impaired torsion was quantified by the correlation between both rotations, where a negative value indicates normal torsion and a positive value indicates a torsion disorder: basal and apical rotations follow the same path. This value was called ‘Torcor’. In patients, LV pressure was measured under atrial-sensed ventricular stimulation, using different pacing combinations. Acute response to CRT was defined by >10% increase in invasively measured dP/dtmax from the best pacing configuration relative to baseline. Torcor was compared between responders, non-responders and controls, and ROC-analysis was performed. Results: Torcor was significantly higher in responders (n=18) than in non-responders (n=17) and controls (0.60±0.55, -0.45±0.55 and 0.68±0.22, resp., p<0.001), but was not significantly different between the non-responder and the control group (p=0.71). ROC analysis resulted in an area under the curve of 0.88, p<0.001, 95% CI: 0.76 to 1.00. The sensitivity and specificity for prediction of response were 83% at a cutoff-value of 0.11.