A. Penhall

Nonvolumetric Echocardiographic Indices of Right Ventricular Systolic Function: Validation with Cardiovascular Magnetic Resonance and Relationship with Functional Capacity

Purpose: Right ventricular (RV) systolic function as measured by right ventricular ejection fraction (RVEF) has long been recognized as an important predictor of outcome in heart failure patients. The echocardiographic measurement of RV volumes and RVEF is challenging, however, owing to the unique geometry of the right ventricle. Several nonvolumetric echocardiographic indices of RV function have demonstrated prognostic value in heart failure. Comparison studies of these techniques with each other using RVEF as a benchmark are limited, however. Furthermore, the contribution of these various elements of RV function to patient functional status is uncertain. We therefore aimed to: (1) Determine which nonvolumetric echocardiographic index correlates best with RVEF as determined by cardiac magnetic resonance (CMR) imaging (the accepted gold standard measure of RV systolic function) and (2) Ascertain which echocardiographic index best predicts functional capacity. Methods: Eighty‐three subjects (66 with systolic heart failure and 17 healthy controls) underwent CMR, 2D echocardiography, and cardiopulmonary exercise testing for comparison of echocardiographic indices of RV function with CMR RVEF, 6‐minute walk distance and VO2 PEAK. Results: Speckle tracking strain RV strain exhibited the closest association with CMR RV ejection fraction. Indices of RV function demonstrated weak correlation with 6‐minute walk distance, but basal RV strain rate by tissue velocity imaging had good correlation with VO2 PEAK. Conclusion: Strain by speckle tracking echocardiography and strain rate by tissue velocity imaging may offer complementary information in the evaluation of RV contractility and its functional effects. (Echocardiography 2012;29:455‐463)

Early effects of transcatheter aortic valve implantation and aortic valve replacement on myocardial function and aortic valve hemodynamics: Insights from cardiovascular magnetic resonance imaging

OBJECTIVES There remains a paucity of mechanistic data on the effect of transcatheter aortic valve implantation (TAVI) on early left and right ventricular function and quantitative aortic valve regurgitation. We sought to assess and compare the early effects on myocardial function and aortic valve hemodynamics of TAVI and aortic valve replacement (AVR) using serial cardiovascular magnetic resonance (CMR) imaging and echocardiography. METHODS A prospective comparison study of 47 patients with severe aortic stenosis undergoing either TAVI (n = 26) or high-risk AVR (n = 21). CMR (for left ventricle/right ventricle function, left ventricular mass, left atrial volume, and aortic regurgitation) was carried out before the procedure and early postprocedure (<14 days). RESULTS Groups were similar with respect to Society of Thoracic Surgeons score (TAVI, 7.7 vs AVR, 5.9; P = .11). Preoperative left ventricular (TAVI, 69% ± 13% vs AVR, 73% ± 10%; P = .10) and right ventricular (TAVI, 61% ± 11% vs AVR, 59% ± 8%; P = .5) ejection fractions were similar. Postoperative left ventricular ejection fraction was preserved in both groups. In contrast, decline in right ventricular ejection fraction was more significant in the TAVI group (61%-54% vs 59%-58%; P = .01). Postprocedure aortic regurgitant fraction was significantly greater in the TAVI group (16% vs 4%; P = .001), as was left atrial size (110 vs 84 mL; P = .02). Further analysis revealed a significant relationship between the increased aortic regurgitant fraction and greater left atrial size (P = .006), and a trend toward association between the decline in right ventricle dysfunction and increased postprocedure aortic regurgitation (P = .08). CONCLUSIONS There was no significant difference in early left ventricular systolic function between techniques. Whereas right ventricle systolic function was preserved in the AVR group, it was significantly impaired early after TAVI, possibly reflecting a clinically important pathophysiologic consequence of paravalvular aortic regurgitation.

Early cardiac changes following anthracycline chemotherapy in breast cancer: a prospective multi-centre study using advanced cardiac imaging and biochemical markers

Summary This prospective study is designed to identify novel ima- ging (utilizing cardiovascular magnetic resonance and advance echocardiography) and biochemical markers to detect early, sub-clinical cardiotoxicity following chemotherapy. Background Cardiac toxicity is an important long term side effect of anthracyline chemotherapy. We hypothesized that novel cardiovascular magnetic resonance (CMR) and echocar- diographic markers of myocardial function, oedema, and necrosis can detect early, subclinical cardiac toxicity in patients receiving anthracycline therapy for breast cancer. recovery fast-spin echo sequence (short-TI inversion recovery) was used in 3 short-axis views of the left ven- tricle. For assessment of myocardial oedema, the ratio of mean signal intensity (SI) of the myocardium was com- pared to that of skeletal muscle. Results In the study patients, the mean CMR LV end-systolic volume index (LVESVI) increased from baseline of 17.8 ± 6.2 to 20.3 ± 5.9 mL/m2 (p 1.9 as specified by Lake Louis criteria) in one or more short axis slices post chemotherapy. There was no new late gadolinium hyperenhancement to suggest focal myocar- dial necrosis/fibrosis in any patient following therapy.

Early and late left ventricular effects of breast cancer chemotherapy: a prospective multi-centre study using advanced cardiac imaging

Background Myocardial dysfunction is a recognized toxicity of anthracycline (A) and herceptin (H) chemotherapy. Whilst there is much current focus on the incidence and magnitude of myocardial dysfunction following the A/H regimen, whether these changes are mediated by reversible or irreversible myocardial injury remains unknown. We sought to determine rates of persistent LV dysfunction at 12 months (as defined by left ventricular ejection fraction (LVEF) decrease by 10% or below lower limits of normal) following A/H and explore the mechanism of myocardial dysfunction using advance cardiac imaging.

A Rare Case of Penetrating Atherosclerotic Ulcer of the Aorta

We are reporting a case of 66 year-old man who presented to a regional hospital with sudden onset of inter-scapular pain, radiating to anterior chest. Initial assessment was unremarkable except for high blood pressure and computed tomography (CT) of chest showing an intramural haematoma in the thoracic descending aorta. He was transferred to our institution for the medical management of his blood pressure and intramural haematoma of the aorta. A transoesophageal echocardiography confirmed the diagnosis but in addition demonstrated a penetrating atherosclerotic ulcer (PAU). Subsequently CT aortogram revealed a slow leak from the PAU. Endovascular repair with stent-grafting was urgently performed. He improved clinically and remained well on discharge. This case demonstrated that PAU, although rare and often under-recognised, is potentially life-threatening and should be considered in the evaluation of chest pain. Multi-modality imaging techniques can aid the diagnosis and guide appropriate and timely management.

Contemporary breast cancer chemotherapy leads to persistent late right ventricular myocardial dysfunction: a prospective multi-centre study

Background Previous studies evaluating cardiac effects of chemotherapy have focussed on the left ventricle (LV) and largely been retrospective. Although right ventricle (RV) systolic dysfunction is an adverse prognostic marker in cardiomyopathy states, the RV effects of chemotherapy are not well defined. Methods

QUANTITATIVE ANALYSIS OF PARAVALVULAR LEAK OF TRANSCATHETER AORTIC VALVES USING CMRI

Transcatheter aortic valve implantation (TAVI) is associated with a significant incidence of paravalvular leak. Cardiovascular magnetic resonance (CMR) directly quantifies aortic regurgitation (AR) with accuracy and reproducibility using phase-contrast velocity mapping. We compare CMR and

Validation of echocardiographic indices of right ventriclular systolic function with cardiac magnetic resonance: a comparative study

Right ventricular ejection fraction (RVEF) is an important predictor of outcome in heart failure patients. Although cardiac magnetic resonance (CMR) assessment of RV function is considered gold standard and echocardiographic measurement of RVEF is challenging due to its unique geometry; CMR still has limited availability in the wider community. Therefore alternative echocardiographic indices such as tricuspid annular plane systolic excursion (TAPSE), peak tricuspid annular systolic velocity (RV S’) and RV fractional area change (RV FAC) have been evaluated and demonstrated prognostic value, however, comparison studies with RVEF by CMR are limited.

Structural and functional characterisation of new-onset idiopathic dilated cardiomyopathy, and its response to therapy

Introduction The prevalence of myocardial fibrosis among patients with idiopathic dilated cardiomyopathy (IDCM), as detected by the late-gadolinium cardiac magnetic resonance (LG-CMR) technique, is reported to be 28-42% in highly-selected samples from specialist heart failure clinics. The presence of fibrosis has been demonstrated to predict the incidence of major adverse cardiovascular events. However, as the heart failure duration prior to first CMR imaging in these studies was at least 12 months the prevalence of myocardial fibrosis at presentation is unknown. Moreover, the determinants of the response-to-therapy of newly diagnosed IDCM patients have not been characterised using CMR and advanced echocardiographic techniques.