Arianna Bocelli

Concordance between M-mode, pulsed Tissue Doppler, and colour Tissue Doppler in the assessment of mitral annulus systolic excursion in normal subjects.

AIMS M-mode left atrioventricular plane displacement (AVPD) correlates with Tissue Doppler (TD) peak systolic annular velocity in healthy individuals. This approach is biased by several interacting factors related to the structural complexity of mitral annulus physiology, including the different dimensional values of measures, the confounding effect of isovolumic motions, and the spectral thickness of pulsed TD envelope. We sought to analyze the effective concordance between techniques in the assessment of systolic annular excursion. METHODS AND RESULTS In 92 healthy subjects (age 60.5 +/- 18.6, 43.5% women), systolic AVPD was measured after exclusion of isovolumic components using three techniques: (i) M-mode; (ii) temporal integration of pulsed TD systolic wave; and (iii) colour TD-derived tissue tracking. Close correlations of M-mode AVPD with pulsed TD velocity-time integral (VTI) (R = 0.90, P < 0.0001) and colour TD AVPD (R = 0.86, P < 0.0001) were found. However, M-mode AVPD underestimated pulsed TD VTI (mean error -5.1 +/- 1.7 mm) and overestimated colour TD AVPD (mean error 3.4 +/- 1.3 mm). The concordance between M-mode and pulsed TD increased after adjustment for spectral dispersion of pulsed TD instantaneous velocities (mean error 0.1 +/- 1.1 mm). CONCLUSION Despite strict correlations exist between M-mode and TD in the assessment of mitral annulus systolic excursion, the effective concordance between techniques is sub-optimal.

Impact of diabetes and hypertension on left ventricular longitudinal systolic function

BACKGROUND The assessment of the longitudinal component of left ventricular (LV) function is of major clinical importance for the early detection of LV contractile impairment. The aim of this study was to compare the impact of isolated type-2 diabetes, isolated hypertension, and co-existence of both on LV longitudinal systolic performance, with particular focus on their potential interaction effect. METHODS The study population included 163 consecutive patients: 84 patients with hypertension, 36 with diabetes, and 43 who have both hypertension and diabetes; 70 healthy controls were also recruited. Systolic mitral annulus velocity (S(m)) by Tissue Doppler and left atrioventricular plane displacement (AVPD) by M-mode were measured in all subjects. RESULTS AVPD was similarly reduced in hypertensives (13.2±2.2mm) and diabetics (13.5±2.3mm) when compared with the controls (15.1±2.4mm), and further depressed in diabetic hypertensives (11.5±3.0mm). Similar results were found for S(m). General linear model analysis revealed no significant interaction terms between diabetes and hypertension. CONCLUSIONS Normotensive diabetics and nondiabetic hypertensives show comparable depression in LV longitudinal systolic indices when compared with age- and gender-matched healthy controls; the co-existence of diabetes and hypertension leads to further impairment in LV longitudinal systolic function in an additive manner.

Left Ventricular Longitudinal Systolic Dysfunction Is an Independent Marker of Cardiovascular Risk in Patients With Hypertension

BACKGROUND To explore the prognostic value of left ventricular (LV) longitudinal systolic dysfunction in patients with hypertension. METHODS In 156 hypertensive subjects, LV longitudinal systolic function was assessed by echocardiographic measurement of M-mode left atrioventricular plane displacement (AVPD) and Tissue Doppler (TD)-derived mitral annulus peak systolic velocity (Sm). Patients were followed for development of the following cardiovascular events: congestive heart failure requiring hospitalization, new-onset angina, nonfatal myocardial infarction, coronary revascularization procedures, transient ischemic attack, nonfatal stroke, and cardiovascular death. RESULTS Over a follow-up of 23.3 +/- 5.4 months, 24 patients had 29 events. Both longitudinal systolic indices were predictive of outcome (hazard ratios: AVPD, 0.24, P < 0.001; Sm, 0.22; P < 0.001). AVPD < or = 11.4 mm (75.0% sensitivity and 53.8% specificity) and Sm < or = 8.9 cm/s (79.2% sensitivity and 61.4% specificity) were identified as the best cutoffs for the prediction of cardiovascular events (area under curve: AVPD, 0.66, P < 0.01; Sm, 0.71; P < 0.0001). Compared to conventional indices of circumferential systolic function, AVPD and Sm showed similar overall diagnostic performance, but higher sensitivity and lower specificity. Coexistence of longitudinal and circumferential systolic dysfunction was associated with the worst prognosis (P < 0.0001). Multivariate analysis confirmed an independent association of longitudinal indices with clinical outcome, incremental to circumferential systolic impairment, and other confounding variables. CONCLUSIONS Longitudinal systolic dysfunction is an independent marker of cardiovascular risk in hypertensive patients. Despite similarity in predictive accuracy, longitudinal indices are more sensitive but less specific than circumferential indices for the prediction of cardiovascular events in these subjects.

Acute effects of low doses of red wine on cardiac conduction and repolarization in young healthy subjects.

BACKGROUND Moderate to high blood concentrations of ethanol have been shown to yield acute changes in cardiac electrophysiological properties, but the effect of low concentrations have never been assessed. The role of concomitant changes in clinical variables or cardiac dimensions is also still unknown. This study aimed at exploring the acute effects of low doses of ethanol, administered as Italian red wine, on conduction, depolarization, and repolarization electrocardiographic (ECG) intervals in a population of healthy subjects. METHODS Forty healthy young volunteers drank a low quantity of red wine (5 ml/kg), and an equal volume of fruit juice in separate experiments. Heart rate, P-wave duration, PR interval, QRS duration, QT interval, corrected QT interval, QT dispersion, and corrected QT dispersion were assessed at baseline and after 60 minutes from challenge. RESULTS Mean blood ethanol concentration after drinking was 0.48 +/- 0.06 g/l. Compared to the control challenge, significant changes after red wine intake were observed in P-wave duration (from 101 +/- 11 to 108 +/- 14 milliseconds, p = 0.0006), PR interval (from 153 +/- 15 to 167 +/- 17 milliseconds, p < 0.0001), QT interval (from 346 +/- 28 to 361 +/- 24 milliseconds, p < 0.0001), and corrected QT interval (from 388 +/- 24 to 402 +/- 30 milliseconds, p = 0.0006). None of these changes showed correlations with modifications in clinical or echocardiographic variables. In multivariate analyses aimed at exploring predictors of ECG changes, none of the variables entered the final models. CONCLUSIONS Low doses of red wine acutely slow cardiac conduction and prolong repolarization in normal individuals. These changes are poorly predictable. The potential arrhythmogenic impact of these effects is worthy of exploration.

What Is the Effective Diagnostic Role of Pediatric Cardiac Assessment in the Offspring of Women With Congenital Heart Disease

To the Editor .— Thangaroopan et al1 recently reported that pediatric cardiac assessment (CA) provided incremental diagnostic yield in comparison with fetal echocardiography (FE) in the offspring of women with congenital heart disease (CHD). We agree with the important role of CA in managing these patients. However, 2 aspects should be considered in interpreting these findings. First, caution is required when considering as effectively incremental the diagnostic information provided by a test in comparison with another when the 2 tests are not performed …

Echocardiographic History of an Asymptomatic Congenital Cardiac Tumor No Changes in Mass Dimensions During a 14-Year Follow-Up

A 14-year-old girl with a history of a congenital cardiac tumor presented to our echocardiography laboratory for a routine reexamination. The diagnosis had been made in our laboratory in 1991 on her seventh day of life using an old-generation ultrasound machine (SSH-40A, Toshiba Medical Systems, Tokyo, Japan). The newborn had undergone echocardiographic evaluation because of a systolic murmur. Despite the low technical quality of the images (Figure 1 and Movie I), a large mass involving the interventricular septum (4.2×1.5 cm, as measured from the apical 4-chamber view), suggestive of a congenital cardiac tumor, was visualized. Subsequent analyses had supported the diagnosis of cardiac rhabdomyoma. No other significant comorbidities, including tuberous sclerosis—a genetic condition often associated with the presence of cardiac rhabdomyoma1—had been discovered. Because of the absence of symptoms, a conservative approach was adopted. Clinical and echocardiographic follow-up during the subsequent years showed substantial tumor stability, with no development of symptoms. Figure 1. Original echocardiographic image obtained in 1991 using an old-generation ultrasound …A14-year-old girl with a history of a congenital cardiac tumor presented to our echocardiography laboratory for a routine reexamination. The diagnosis had been made in our laboratory in 1991 on her seventh day of life using an old-generation ultrasound machine (SSH-40A, Toshiba Medical Systems, Tokyo, Japan). The newborn had undergone echocardiographic evaluation because of a systolic murmur. Despite the low technical quality of the images (Figure 1 and Movie I), a large mass involving the interventricular septum (4.2 1.5 cm, as measured from the apical 4-chamber view), suggestive of a congenital cardiac tumor, was visualized. Subsequent analyses had supported the diagnosis of cardiac rhabdomyoma. No other significant comorbidities, including tuberous sclerosis—a genetic condition often associated with the presence of cardiac rhabdomyoma1—had been discovered. Because of the absence of symptoms, a conservative approach was adopted. Clinical and echocardiographic follow-up during the subsequent years showed substantial tumor stability, with no development of symptoms. At the present examination, the girl was asymptomatic and in good condition. Two-dimensional echocardiography (Sonos 7500 Live 3D Echo, Philips Medical Systems, Andover, Mass) showed an inhomogeneous echogenic mass arising from the mid-apical portion of the interventricular septum (Figures 2 to 4). The dimensions of the mass at end-diastole were similar to those measured at birth (4.4 cm, 1.6 cm, and 3.0 cm in the craniocaudal, transverse, and anteroposterior axis, respectively). In accordance with the muscular nature of the tumor, the mass showed a slight thickening throughout systole (Movies II to IV). The rest of the heart was structurally normal, and no functional abnormalities were found. Real-time 3-dimensional imaging and offline quantitative analysis of data (3DQ-QLAB advanced quantification software, version 3.0, Philips Ultrasound) allowed detailed visualization of the mass, revealing an irregular multilobed architecture with inhomogeneous echogenicity and a torsional–dyskinetic movement during systole (Figures 5 and 6 and Movie V). Tumor dimensions were only slightly larger than those measured by the 2-dimensional approach (craniocaudal: 4.6 cm; transverse: 1.8 cm; anteroposterior: 3.1 cm; volume: 13.9 cm). Congenital cardiac tumors are rare occurrences, having a prevalence of 0.14%.2 Rhabdomyomas are the most common tumors, accounting for about 50% of all cases in children.3 A strong association with tuberous sclerosis has been reported. Among subjects with cardiac rhabdomyoma, 51% to 86% have tuberous sclerosis, whereas more than half of patients with tuberous sclerosis show cardiac rhabdomyomas.1 These rhabdomyomas are usually characterized by multiple masses, with a peduncolated or rounding intramural shape, and they most commonly involve the ventricular myocardium. Cardiac rhabdomyomas may present at birth with a wide spectrum of clinical features, ranging from occasional echocardiographic detection in asymptomatic newborns to presentations with cardiac rhythm disturbances, Wolff-Parkinson-White syndrome, congestive heart failure caused by flow obstruction or valve regurgitation, and/or sudden death. Cardiac symptoms represent a common finding in the first years of life, but spontaneous regression of the tumor occurs in the majority of cases.4 These images illustrate the echocardiographic history of an isolated congenital cardiac rhabdomyoma in an asymptomatic female patient. The evolution of ultrasound techniques—particularly the possibility of performing realtime 3-dimensional imaging— has allowed considerably higher definition of tumor characteristics throughout years. The following unusual aspects should also be pointed out: 1) The tumor was not associated with tuberous sclerosis; 2) the rhabdomyoma was characterized by a single, multilobed mass; 3) the patient did not develop any cardiac symptom; and 4) the dimensions of the mass did not change significantly during a 14-year follow-up.

A new method to estimate left ventricular circumferential midwall systolic function by standard echocardiography: Concordance between models and validation by speckle tracking

BACKGROUND Assessment of left ventricular circumferential (LVcirc) systolic function by standard echocardiography can be performed by estimating midwall fractional shortening (mFS) and stress-corrected mFS (ScmFS). Their determination is based on spherical or cylindrical LV geometric models, which often yield discrepant values. We developed a new model based on a more realistic truncated ellipsoid (TE) LV shape, and explored the concordance between models among hypertensive patients. We also compared the relationships of different mFS and ScmFS estimates with indexes of LVcirc systolic strain. METHODS In 364 hypertensive subjects, mFS was determined using the spherical (mFSspher), cylindrical (mFScyl), and TE model (mFSTE). Corresponding values of ScmFSspher, ScmFScyl, and ScmFSTE were obtained. Global circumferential strain (GCS) and systolic strain rate (GCSR) were also measured by speckle tracking. RESULTS The three models showed poor concordance for the estimation of mFS, with average differences ranging between 11% and 30% and wide limits of agreement. Similar results were found for ScmFS, where reclassification rates for the identification of abnormal LVcirc systolic function ranged between 18% and 29%. When tested against strain indexes, mFSTE and ScmFSTE showed the best correlations (R=0.81 and R=0.51, p<0.0001 for both) with GCS and GCSR. Multivariable analysis confirmed that mFSTE and ScmFSTE showed the strongest independent associations with LVcirc strain measures. CONCLUSIONS Substantial discrepancies in LVcirc midwall systolic indexes exist between different models, supporting the need of model-specific normative data. The use of the TE model might provide indexes that show the best associations with established strain measures of LVcirc systolic function.

Letter by Ballo et al Regarding Article, “Serial Biomarker Measurements in Ambulatory Patients With Chronic Heart Failure: The Importance of Change Over Time”

To the Editor: We greatly appreciated the article by Miller et al.1 In contrast to several studies showing a major role of brain natriuretic peptide (BNP) as a predictor of adverse prognosis in heart failure,2,3 the study by Miller et al reported that elevated BNP at baseline was not significantly associated with outcome (primary end point: death/cardiac transplantation) in a cohort of 190 patients with New York Heart Association class III-IV heart failure who were followed up for 24 months, after adjustment for troponin T levels, …

Letter by Bocelli et al Regarding Article, “A Novel Method of Expressing Left Ventricular Mass Relative to Body Size in Children”

To the Editor: In the recent interesting article by Foster et al,1 the standard method of indexing left ventricular (LV) mass to height2.7 was found to be inadequate to adjust for body size in a reference population that included healthy individuals from birth to 21 years of age. In particular, LV mass index (LVMI) was relatively independent of height in taller subjects but showed a strong residual correlation with height in subjects <100 cm tall, ie, in newborns, infants, and children in their first years of life. In contrast, a more complex method based on percentile curves provided adequate normalization to body size, with …

Prognostic value of LV long-axis versus short-axis systolic function in heart failure

To the Editor: Gruner Svealv et al recently found that left ventricular (LV) long-axis atrioventricular plane displacement (AVPD) in patients with heart failure (HF) was linearly correlated with short-axis fractional shortening (LVFS) in the lower range of AVPD, but not in the higher range of AVPD.1 They also observed that decreasing AVPD quartiles showed a stepwise association with worsening prognosis. Notably, a similar gradual association with outcome was less evident for LVFS, …