Alik Sagie

Reliability of Visual Assessment of Global and Segmental Left Ventricular Function: A Multicenter Study by the Israeli Echocardiography Research Group

BACKGROUND The purpose of this multicenter study was to determine the reliability of visual assessments of segmental wall motion (WM) abnormalities and global left ventricular function among highly experienced echocardiographers using contemporary echocardiographic technology in patients with a variety of cardiac conditions. METHODS The reliability of visual determinations of left ventricular WM and global function was calculated from assessments made by 12 experienced echocardiographers on 105 echocardiograms recorded using contemporary echocardiographic equipment. Ten studies were reread independently to determine intraobserver reliability. RESULTS Interobserver reliability for visual differentiation between normal, hypokinetic, and akinetic segments had an intraclass correlation coefficient of 0.70. The intraclass correlation coefficient for dichotomizing segments into normal versus other abnormal was 0.63, for hypokinetic versus other scores was 0.26, and for akinetic versus other scores was 0.58. Similar results were found for intraobserver reliability. Interobserver reliability for WM score index was 0.84 and for left ventricular ejection fraction was 0.78. Similar values were obtained for the intraobserver reliability of WM score index and ejection fraction. Compared to angiographic data, the accuracy of segmental WM assessments was 85%, and correct determination of the culprit artery was achieved in 59% of patients with myocardial infarctions. CONCLUSION Among experienced readers using contemporary echocardiographic equipment, interobserver and intraobserver reliability was reasonable for the visual quantification of normal and akinetic segments but poor for hypokinetic segments. Reliability was good for the visual assessment of global left ventricular function by WM score index and ejection fraction.

A new tool for automatic assessment of segmental wall motion based on longitudinal 2D strain: a multicenter study by the Israeli Echocardiography Research Group.

Background— Identification and quantification of segmental left ventricular wall motion abnormalities on echocardiograms is of paramount clinical importance but is still performed by a subjective visual method. We constructed an automatic tool for assessment of wall motion based on longitudinal strain. Methods and Results— Echocardiograms of 105 patients (3 apical views) were blindly analyzed by 12 experienced readers. Visual segmental scores (VSS) and peak systolic longitudinal strain were assigned to each of 18 segments per patient. Ranges of peak systolic longitudinal strain that best fit VSS (by receiver operating characteristic analysis) were used to generate automatic segmental scores (ASS). Comparisons of ASS and VSS were performed on 1952 analyzable segments. There was agreement of wall motion scores between both methods in 89.6% of normal, 39.5% of hypokinetic, and 69.4% of akinetic segments. Correlation between methods was r =0.63 ( P <0.0001). Interobserver and intraobserver reliability using interclass correlation for scoring segmental wall motion into 3 scores by ASS was 0.82 and 0.83 and by VSS 0.70 and 0.69, respectively. Compared with VSS (majority rule), ASS had a sensitivity, specificity, and accuracy of 87%, 85%, and 86%, respectively. ASS and VSS had similar success rates for correct identification of wall motion abnormalities in territories supplied by culprit arteries. VSS had greater specificity and positive predictive values, whereas ASS had higher sensitivity and negative predictive values for identifying the culprit artery. Conclusions— Automatic quantification of wall motion on echocardiograms by this tool performs as well as visual analysis by experienced echocardiographers, with a greater reliability and similar agreement to angiographic findings. Received December 16, 2008; accepted November 17, 2009. # CLINICAL PERSPECTIVE {#article-title-2}Background—Identification and quantification of segmental left ventricular wall motion abnormalities on echocardiograms is of paramount clinical importance but is still performed by a subjective visual method. We constructed an automatic tool for assessment of wall motion based on longitudinal strain. Methods and Results—Echocardiograms of 105 patients (3 apical views) were blindly analyzed by 12 experienced readers. Visual segmental scores (VSS) and peak systolic longitudinal strain were assigned to each of 18 segments per patient. Ranges of peak systolic longitudinal strain that best fit VSS (by receiver operating characteristic analysis) were used to generate automatic segmental scores (ASS). Comparisons of ASS and VSS were performed on 1952 analyzable segments. There was agreement of wall motion scores between both methods in 89.6% of normal, 39.5% of hypokinetic, and 69.4% of akinetic segments. Correlation between methods was r=0.63 (P<0.0001). Interobserver and intraobserver reliability using interclass correlation for scoring segmental wall motion into 3 scores by ASS was 0.82 and 0.83 and by VSS 0.70 and 0.69, respectively. Compared with VSS (majority rule), ASS had a sensitivity, specificity, and accuracy of 87%, 85%, and 86%, respectively. ASS and VSS had similar success rates for correct identification of wall motion abnormalities in territories supplied by culprit arteries. VSS had greater specificity and positive predictive values, whereas ASS had higher sensitivity and negative predictive values for identifying the culprit artery. Conclusions—Automatic quantification of wall motion on echocardiograms by this tool performs as well as visual analysis by experienced echocardiographers, with a greater reliability and similar agreement to angiographic findings.

Intracardiac echocardiography: in vitro and in vivo validation for right ventricular volume and function.

To determine the feasibility and accuracy of intracardiac ultrasonography (ICUS) for the measurement of right ventricular (RV) volumes and function, a 10 MHz ICUS catheter was used in an in vitro and in vivo model. In the in vitro study, 16 sheep hearts were imaged. Sequential cross-sectional images from RV apex to base were recorded during a calibrated pullback. Volumes were calculated by applying Simpsons algorithm. ICUS-obtained volumes correlated well with actual volumes (standard error of estimate [SEE] = 2.3 ml, r = 0.98). For the in vivo study, a beating-heart canine model was used (31 hemodynamic stages in six dogs). Actual volumes were measured by an intracavitary balloon connected to an external column. Sequential cross-sectional images were recorded during the ICUS catheter pullback from apex to base of the RV, and volumes calculated by Simpsons algorithm. Good correlations were observed between ICUS and actual values for diastolic (SEE = 4.1 ml, r = 0.97), systolic (SEE = 3.4 ml, r = 0.96), and ejection fraction (SEE = 3.1%, r = 0.87) values. This new technique can accurately quantitate RV volumes, can function both in vitro and in vivo, and has the potential for increasing applications to questions of clinical and research interest.

The safety and efficacy of repeated courses of tissue-type plasminogen activator in patients with stuck mitral valves who did not fully respond to the initial thrombolytic course

Summary.  In carefully selected patients with stuck mitral valves, thrombolytic therapy is becoming an established therapeutic modality. However, the management of patient with a suboptimal response to an initial thrombolytic course is unclear. The objective was to evaluate the efficacy and safety of re‐administration of tissue‐type plasminogen activator (rt‐PA) in patients with stuck mitral valves in whom the first thrombolytic course has failed to restore normal prosthetic valve function. The study group included patients who received rt‐PA and did achieve a full restoration of valve function after the initial course. Data were gathered on the safety and success rates of additional thrombolytic courses in the same hospitalization period, and their predictors. Twelve patients with stuck mitral valves experienced a total of 13 episodes in which a full resolution of leaflet abnormality was not achieved after the initial thrombolytic course. A repeated thrombolytic course was attempted in 10 patients (11 episodes). Six patients (60%) showed full success rate with repeated thrombolysis, one (10%) showed partial success, and three patients (30%) had no improvement following the second course. These last three were those with initial failure. Age, gender, valve model, worst functional class, time since valve implantation and International Normalized Ratio (INR) levels were similar in both groups. No major adverse events were noted.

Is It Time to Revise the Guidelines and Recommendations for Digital Echocardiography

The first comprehensive recommendations for digital echocardiography were published in 2005. They had a huge impact on the entire development of echocardiography and contributed to an early transition from videotape to an all-digital solution. Since then, there have been no recommendations for digital echocardiography, despite the dramatic development of computer technology and echocardiography machines. For example, the typical echocardiographic video frame rate increased from 30 fps to 40-120 fps, network speed increased from 100 Mbps to 1,000 Mbps and more, CD-ROMs disappeared, and so on.

Association Between Mitral Annular Calcium and Flail Mitral Leaflet in Degenerative Mitral Valve Disease

The aim of this study was to assess the association between mitral annular calcium (MAC) and flail mitral leaflets in a cohort of patients with degenerative mitral valve disease. A retrospective study was conducted of consecutive patients with degenerative mitral valve disease who underwent echocardiography at Rabin Medical Center from 2003 to 2012. Special focus was attended to the presence and grade of MAC and characterization of valve pathology (myxomatous vs nonmyxomatous, prolapse vs flail). Patients were excluded if they had undergone previous mitral valve surgery and/or had infective endocarditis. Multivariate logistic regressions were used to control for confounders. The study included 1,912 patients (60.8% men, mean age 63.8 ± 17.4 years) divided into 3 groups: 1,627 (86%) without MAC, 183 (10%) with either mild or moderate MAC, and 94 (5%) with severe MAC. The presence of flail leaflet was 27%, 30%, and 46% in these groups, respectively (p <0.001). After adjustment for age, gender, and co-morbidities, the odd ratio for flail mitral leaflet with severe MAC versus no MAC was 1.76 (95% confidence interval 1.10 to 2.83, p = 0.019). In conclusion, this study demonstrates that degenerative mitral valve disease with severe MAC is significantly associated with flail mitral leaflet.

Percutaneous coronary intervention of the left main artery before MitraClip implantation.

Functional mitral regurgitation (MR) is common in patients with ischemic cardiomyopathy. We present a case of an 83-year-old patient with ischemic heart disease and ischemic cardiomyopathy, who was repeatedly admitted for pulmonary edema and underwent a percutaneous trans-septal MitraClip procedure. During coronary angiography, a severe left main stenosis was demonstrated. Treatment included both percutaneous coronary intervention and the implantation of two MitraClip devices, with very good results. We believe that this case illustrates the need for comprehensive assessment of ischemia in patients with functional MR.

A New Tool for Automatic Assessment of Segmental Wall Motion Based on Longitudinal 2D StrainCLINICAL PERSPECTIVE: A Multicenter Study by the Israeli Echocardiography Research Group

Background— Identification and quantification of segmental left ventricular wall motion abnormalities on echocardiograms is of paramount clinical importance but is still performed by a subjective visual method. We constructed an automatic tool for assessment of wall motion based on longitudinal strain. Methods and Results— Echocardiograms of 105 patients (3 apical views) were blindly analyzed by 12 experienced readers. Visual segmental scores (VSS) and peak systolic longitudinal strain were assigned to each of 18 segments per patient. Ranges of peak systolic longitudinal strain that best fit VSS (by receiver operating characteristic analysis) were used to generate automatic segmental scores (ASS). Comparisons of ASS and VSS were performed on 1952 analyzable segments. There was agreement of wall motion scores between both methods in 89.6% of normal, 39.5% of hypokinetic, and 69.4% of akinetic segments. Correlation between methods was r =0.63 ( P <0.0001). Interobserver and intraobserver reliability using interclass correlation for scoring segmental wall motion into 3 scores by ASS was 0.82 and 0.83 and by VSS 0.70 and 0.69, respectively. Compared with VSS (majority rule), ASS had a sensitivity, specificity, and accuracy of 87%, 85%, and 86%, respectively. ASS and VSS had similar success rates for correct identification of wall motion abnormalities in territories supplied by culprit arteries. VSS had greater specificity and positive predictive values, whereas ASS had higher sensitivity and negative predictive values for identifying the culprit artery. Conclusions— Automatic quantification of wall motion on echocardiograms by this tool performs as well as visual analysis by experienced echocardiographers, with a greater reliability and similar agreement to angiographic findings. Received December 16, 2008; accepted November 17, 2009. # CLINICAL PERSPECTIVE {#article-title-2}Background—Identification and quantification of segmental left ventricular wall motion abnormalities on echocardiograms is of paramount clinical importance but is still performed by a subjective visual method. We constructed an automatic tool for assessment of wall motion based on longitudinal strain. Methods and Results—Echocardiograms of 105 patients (3 apical views) were blindly analyzed by 12 experienced readers. Visual segmental scores (VSS) and peak systolic longitudinal strain were assigned to each of 18 segments per patient. Ranges of peak systolic longitudinal strain that best fit VSS (by receiver operating characteristic analysis) were used to generate automatic segmental scores (ASS). Comparisons of ASS and VSS were performed on 1952 analyzable segments. There was agreement of wall motion scores between both methods in 89.6% of normal, 39.5% of hypokinetic, and 69.4% of akinetic segments. Correlation between methods was r=0.63 (P<0.0001). Interobserver and intraobserver reliability using interclass correlation for scoring segmental wall motion into 3 scores by ASS was 0.82 and 0.83 and by VSS 0.70 and 0.69, respectively. Compared with VSS (majority rule), ASS had a sensitivity, specificity, and accuracy of 87%, 85%, and 86%, respectively. ASS and VSS had similar success rates for correct identification of wall motion abnormalities in territories supplied by culprit arteries. VSS had greater specificity and positive predictive values, whereas ASS had higher sensitivity and negative predictive values for identifying the culprit artery. Conclusions—Automatic quantification of wall motion on echocardiograms by this tool performs as well as visual analysis by experienced echocardiographers, with a greater reliability and similar agreement to angiographic findings.

A New Tool for Automatic Assessment of Segmental Wall Motion Based on Longitudinal 2D StrainCLINICAL PERSPECTIVE

Background— Identification and quantification of segmental left ventricular wall motion abnormalities on echocardiograms is of paramount clinical importance but is still performed by a subjective visual method. We constructed an automatic tool for assessment of wall motion based on longitudinal strain. Methods and Results— Echocardiograms of 105 patients (3 apical views) were blindly analyzed by 12 experienced readers. Visual segmental scores (VSS) and peak systolic longitudinal strain were assigned to each of 18 segments per patient. Ranges of peak systolic longitudinal strain that best fit VSS (by receiver operating characteristic analysis) were used to generate automatic segmental scores (ASS). Comparisons of ASS and VSS were performed on 1952 analyzable segments. There was agreement of wall motion scores between both methods in 89.6% of normal, 39.5% of hypokinetic, and 69.4% of akinetic segments. Correlation between methods was r =0.63 ( P <0.0001). Interobserver and intraobserver reliability using interclass correlation for scoring segmental wall motion into 3 scores by ASS was 0.82 and 0.83 and by VSS 0.70 and 0.69, respectively. Compared with VSS (majority rule), ASS had a sensitivity, specificity, and accuracy of 87%, 85%, and 86%, respectively. ASS and VSS had similar success rates for correct identification of wall motion abnormalities in territories supplied by culprit arteries. VSS had greater specificity and positive predictive values, whereas ASS had higher sensitivity and negative predictive values for identifying the culprit artery. Conclusions— Automatic quantification of wall motion on echocardiograms by this tool performs as well as visual analysis by experienced echocardiographers, with a greater reliability and similar agreement to angiographic findings. Received December 16, 2008; accepted November 17, 2009. # CLINICAL PERSPECTIVE {#article-title-2}Background—Identification and quantification of segmental left ventricular wall motion abnormalities on echocardiograms is of paramount clinical importance but is still performed by a subjective visual method. We constructed an automatic tool for assessment of wall motion based on longitudinal strain. Methods and Results—Echocardiograms of 105 patients (3 apical views) were blindly analyzed by 12 experienced readers. Visual segmental scores (VSS) and peak systolic longitudinal strain were assigned to each of 18 segments per patient. Ranges of peak systolic longitudinal strain that best fit VSS (by receiver operating characteristic analysis) were used to generate automatic segmental scores (ASS). Comparisons of ASS and VSS were performed on 1952 analyzable segments. There was agreement of wall motion scores between both methods in 89.6% of normal, 39.5% of hypokinetic, and 69.4% of akinetic segments. Correlation between methods was r=0.63 (P<0.0001). Interobserver and intraobserver reliability using interclass correlation for scoring segmental wall motion into 3 scores by ASS was 0.82 and 0.83 and by VSS 0.70 and 0.69, respectively. Compared with VSS (majority rule), ASS had a sensitivity, specificity, and accuracy of 87%, 85%, and 86%, respectively. ASS and VSS had similar success rates for correct identification of wall motion abnormalities in territories supplied by culprit arteries. VSS had greater specificity and positive predictive values, whereas ASS had higher sensitivity and negative predictive values for identifying the culprit artery. Conclusions—Automatic quantification of wall motion on echocardiograms by this tool performs as well as visual analysis by experienced echocardiographers, with a greater reliability and similar agreement to angiographic findings.

902 Bileaflet mitral valve orientation — is it associated with obstructive valve thrombosis? A transesophageal echocardiographic study

2 , 2 Institute for Cardiovascular Diseases, Belgrade, Yugoslavia Objective: Preservation of the posterior leaflet during mitral valve replacement in patients (pts) with mitral regurgitation has been proven beneficial for postoperative left ventricular performance. Some authors have been stating that posterior leaflet preservation during every mitral valve replacement was highly beneficial both post- operatively as well as long-term. The aim of our study was to investigate long-term effect of this technique in pts with rheumatic mitral stenosis. Patients and Methods: We studied 20 pts with mitral valve replacement for rheumatic mitral stenosis operated from 1989-1990. In all pts a Carbomedics valve was inserted. In group A (10 pts) the posterior leaflet was preserved, while group B (10 pts) underwent excision of both leaflets with corresponding chordas. In both groups hemodynamic characteristic of the valve and the left ventricle, based on echocardiographic findings 12 years later, were compared. We determined maxi- mal (PG) and mean (MG) transmitral valvular gradients, as well as the effective area of inserted valvular opening (AREA), telediastolic (TDV) and telesystolic (TSV) left ventricular volume, stroke volume (SV), ejection fraction (EF), fractional shortening (FS) and segmental left ventricular motion. Results: The mean size of inserted valve was 27.4 in group A and 26.6 in group B. We found no difference between the two groups according to hemodynamic data: PG (10.4 vs 11.1mmHg), MG (4.0 vs 3.5 mmHg), AREA (2.3 vs 2.37cm2), TDV (114.5 vs 133.7ccm), TSV (36.6 vs 46.2ccm), SV (53.7 vs 83.7ccm), EF (67.1 vs 63.7%), FS (38.2 vs 33.7%). Dyskinesis of the corresponding segments was found in 3 patiens in group A and in one patient in group B. Conclusion: In pts with rheumatic mitral stenosis and valve replacement, posterior leaflet preservation has not been shown beneficial for left ventricular function during long-term follow-up. Adequate preservation of the posterior mitral leaflet did not change the properties of the inserted valve in long-term follow-up.