Akio Inage

Normal Rotational, Torsion and Untwisting Data in Children, Adolescents and Young Adults

BACKGROUND Left ventricular (LV) torsion and untwisting are important components of LV performance, but there is little information on the effect of age, particularly in younger populations. METHODS LV rotation and LV rotation rate, torsion, recoiling, and untwisting were measured in normal subjects (n=111) aged 3 to 40 years (mean age, 19.3 years) using speckle-tracking imaging. RESULTS LV torsion increased with age because of the augmentation of apical LV rotation, but this disappeared when normalized by LV length. Although peak LV torsion and apical LV rotation increased with age, the normalized peak torsion rate decreased. As well, the peak untwisting rate decreased with age and was enhanced when normalized by LV length. Younger hearts demonstrated greater untwisting and recoiling of the apex during isovolumic relaxation and early diastole. The time difference between apical and basal events decreased with advancing age. CONCLUSION The heart maintains a constant LV torsion and LV rotation profile when normalized by length and cardiac cycle. Younger hearts tend to twist, untwist, and deform faster.

Two-Dimensional Versus Transthoracic Real-Time Three-Dimensional Echocardiography in the Evaluation of the Mechanisms and Sites of Atrioventricular Valve Regurgitation in a Congenital Heart Disease Population

BACKGROUND Data are lacking on the utility of real-time three-dimensional (3D) echocardiography (RT3DE) in congenital abnormalities of the atrioventricular (AV) valves. The purpose of this study was to determine whether transthoracic RT3DE is superior to combined transthoracic echocardiography and two-dimensional (2D) transesophageal echocardiography in determining mechanisms and sites of AV valve regurgitation in congenital heart disease. METHODS Between January 2005 and November 2007, 48 consecutive patients were studied prior to AV valve repair (22 left AV valves and 26 tricuspid valves) using 2D transthoracic echocardiography, 2D transesophageal echocardiography, and transthoracic RT3DE. Ages ranged from 24 days to 30 years. The 2D data were reviewed by blinded observers, and the real-time 3D data by a separate observer. In all patients, surgical findings were documented by a surgical report, while in 40, video recordings were also available. Surgical findings were used as the reference standard for structural abnormalities; RT3DE was the reference standard for the site of AV valve regurgitation. RESULTS Compared with 2D echocardiography, RT3DE provided superior detail of the mural leaflet and anterior commissural abnormalities for the left AV valve. For the tricuspid valve, improved detection of leaflet abnormalities, prolapse of the anterior and posterior leaflets, and commissural pathology was observed by RT3DE. Apart from a central location, surgical saline testing correlated poorly with jet location on RT3DE. CONCLUSION RT3DE provides complementary information as to the mechanisms and sites of AV valve failure in congenital heart disease.

Real-Time 3-Dimensional Echocardiography Provides New Insight Into Mechanisms of Tricuspid Valve Regurgitation in Patients With Hypoplastic Left Heart Syndrome

Background— Tricuspid regurgitation in hypoplastic left heart syndrome has an impact on outcome, but its mechanisms remain unclear. Methods and Results— Real-time 3-dimensional echocardiography was performed in 35 patients with hypoplastic left heart syndrome (age, 1 month to 10 years; 10 after first-stage Norwood, 12 after superior cavopulmonary shunt, 13 after Fontan). From the 3-dimensional data set, we marked the annulus in systole and diastole. At mid systole, we marked the location of the papillary muscle tip and point of chordal attachment to the leaflet. We traced the surfaces of the tricuspid valve leaflets and measured the volume of leaflet prolapse, tethering, annular and septal leaflet areas, and papillary muscle position. Seventeen patients had moderate tricuspid regurgitation (prolapse, 7; tethered leaflets, 7) and 18 mild (prolapse, 0; tethered leaflets, 7). Multiple linear regression analysis revealed that moderate tricuspid regurgitation is associated with leaflet tethering and prolapse; that in hypoplastic left heart syndrome with tethered leaflets, the papillary muscle is displaced laterally and the tricuspid annulus is more planar; and that enlargement of the annulus at mid systole, small septal leaflet area, and age affect the degree of prolapse. Conclusion— In hypoplastic left heart syndrome, moderate tricuspid regurgitation may be associated with increasing age, geometrical changes of the annulus, leaflet prolapse, lateral papillary muscle displacement, and subsequent leaflet tethering, as well as a smaller septal leaflet.

Defining Left Ventricular Apex-to-Base Twist Mechanics Computed From High-Resolution 3D Echocardiography: Validation Against Sonomicrometry

OBJECTIVES To compute left ventricular (LV) twist from 3-dimensional (3D) echocardiography. BACKGROUND LV twist is a sensitive index of cardiac performance. Conventional 2-dimensional based methods of computing LV twist are cumbersome and subject to errors. METHODS We studied 10 adult open-chest pigs. The pre-load to the heart was altered by temporary controlled occlusion of the inferior vena cava, and myocardial ischemia was produced by ligating the left anterior descending coronary artery. Full-volume 3D loops were reconstructed by stitching of pyramidal volumes acquired from 7 consecutive heart beats with electrocardiography gating on a Philips IE33 system (Philips Medical Systems, Andover, Massachusetts) at baseline and other steady states. Polar coordinate data of the 3D images were entered into an envelope detection program implemented in MatLab (The MathWorks, Inc., Natick, Massachusetts), and speckle motion was tracked using nonrigid image registration with spline-based transformation parameterization. The 3D displacement field was obtained, and rotation at apical and basal planes was computed. LV twist was derived as the net difference of apical and basal rotation. Sonomicrometry data of cardiac motion were also acquired from crystals anchored to epicardium in apical and basal planes at all states. RESULTS The 3D dense tracking slightly overestimated the LV twist, but detected changes in LV twist at different states and showed good correlation (r = 0.89) when compared with sonomicrometry-derived twist at all steady states. In open chest pigs, peak cardiac twist was increased with reduction of pre-load from inferior vena cava occlusion from 6.25 degrees +/- 1.65 degrees to 9.45 degrees +/- 1.95 degrees . With myocardial ischemia from left anterior descending coronary artery ligation, twist was decreased to 4.90 degrees +/- 0.85 degrees (r = 0.8759). CONCLUSIONS Despite lower spatiotemporal resolution of 3D echocardiography, LV twist and torsion can be computed accurately.

Mechanisms of Left Ventricular Dysfunction Assessed by Layer-Specific Strain Analysis in Patients With Repaired Tetralogy of Fallot

BACKGROUND Left ventricular (LV) dysfunction in patients with repaired tetralogy of Fallot (rTOF) is an important risk factor for adverse outcomes. The aim of this study was to assess the details and time course of such LV dysfunction using layer-specific strain analysis by echocardiography.Methods and Results:The 66 patients with rTOF (mean age, 16.3±9.3 years) were divided into 3 groups (T1: 4-10 years, T2: 11-20 years, T3: 21-43 years), and 113 controls of similar age (mean age, 17.2±9.3 years) were divided into 3 corresponding groups (C1, C2, and C3). Layer-specific longitudinal strain (LS) and circumferential strain (CS) of 3 myocardial layers (endocardial, midmyocardial, and epicardial) were determined by echocardiography. Basal and papillary endocardial CS values were decreased in T1 compared with C1. With the exception of papillary epicardial CS, basal/papillary CS and LS of all 3 layers decreased in T2 compared with C2. Excepting papillary epicardial CS, all other values were decreased in T3 compared with C3. CONCLUSIONS Potential myocardial damage was found in the endocardium at the basal and papillary levels of the LV in young patients with rTOF, extending from the endocardium to the epicardium and from the base to the apex. This is the possible time course of LV dysfunction in patients with rTOF.

EVALUATION OF RIGHT VENTRICULAR MYOCARDIAL DEFORMATION AND TRICUSPID VALVE DISPLACEMENT IN REPAIRED TETRALOGY OF FALLOT USING FEATURE TRACKING MAGNETIC RESONANCE STRAIN

The objective of this study was to investigate into correlation between right ventricular (RV) myocardial deformation and tricuspid valve (TV) displacement, and functional parameters in repaired tetralogy of Fallot (TOF) compared to normal subjects using new magnetic resonance tracking program. We

ASSESSMENT OF RIGHT ATRIAL PRESSURE IN CHILDREN WITH CONGENITAL HEART DISEASE: SIMULTANEOUS THREE-DIMENSIONAL ECHOCARDIOGRAPHY AND CATHETERIZATION STUDY

Echocardiographic estimation of right atrial pressure (RAP) using inferior vena cava (IVC) dimensions and its collapsibility in children remains controversial. To access IVC measurements without the influence of translation of IVC into another plane during respiration is essential but challenging.

Long-Term Outcomes of Definitive Surgical Repair for Congenitally Corrected Transposition of the Great Arteries

Long-Term Outcomes of Definitive Surgical Repair for Congenitally Corrected Transposition of the Great Arteries Yuki Nakamoto1),Tomomi Nishimura1),Kanako Kishiki1),Akio Inage1),Tomomi Ueda1), Tadahiro Yoshikawa1),In-Sam Park1),Yasuo Murakami1),Naoki Wada2),Makoto Ando2),Yukihiro Takahashi2) Departments of Pediatric Cardiology1) and Cardiovascular Surgery2), Sakakibara Heart Institute, Tokyo, Japan