C. Hamilton-Craig

Prospective Comparison of Valve Regurgitation Quantitation by Cardiac Magnetic Resonance Imaging and Transthoracic Echocardiography

Background—Both transthoracic echocardiography (TTE) and cardiac magnetic resonance (CMR) imaging allow quantification of chronic aortic regurgitation (AR) and mitral regurgitation (MR). We hypothesized that CMR measurement of regurgitant volume (RVol) is more reproducible than TTE. Methods and Results—TTE and CMR performed on the same day in 57 prospectively enrolled adults (31 with AR, 26 with MR) were measured by 2 independent physicians. TTE RVolAR was calculated as Doppler left ventricular outflow minus inflow stroke volume. RVolMR was calculated by both the proximal isovelocity surface area method and Doppler volume flow at 2 sites. CMR RVolAR was calculated by phase-contrast velocity mapping at the aortic sinuses and RVolMR as total left ventricular minus forward stroke volume. Intraobserver and interobserver variabilities were similar. For AR, the Bland–Altman mean interobserver difference in RVol was −0.7 mL (95% confidence interval [CI], −5 to 4) for CMR and −9 mL (95% CI, −53 to −36) for TTE. The Pearson correlation was higher (P=0.001) between CMR (0.99) than TTE readers (0.89). For MR, the Bland–Altman mean difference in RVol between observers was −4 mL (95% CI, −21 to 13) for CMR compared with 0.7 mL (95% CI, −30 to 32) for the proximal isovelocity surface area and −10 mL (95% CI, −76 to 56) for TTE volume flow at 2 sites. Correlation was similar for CMR (0.94) versus TTE readers (0.90 for the proximal isovelocity surface area). Conclusions—Compared with TTE, CMR has lower intraobserver and interobserver variabilities for RVolAR, suggesting CMR may be superior for serial measurements. Although RVolMR is similar by TTE and CMR, variability in measured RVol by both approaches suggests that caution is needed in clinical practice.

Diagnostic performance and cost of CT angiography versus stress ECG — A randomized prospective study of suspected acute coronary syndrome chest pain in the emergency department (CT-COMPARE) ☆ ☆☆

BACKGROUND Coronary CT angiography (CCTA) has high sensitivity, with 3 recent randomized trials favorably comparing CCTA to standard-of-care. Comparison to exercise stress ECG (ExECG), the most available and least expensive standard-of-care worldwide, has not been systematically tested. METHODS CT-COMPARE was a randomized, single-center trial of low-intermediate risk chest pain subjects undergoing CCTA or ExECG after the first negative troponin. From March 2010 to April 2011, 562 patients randomized to either dual-source CCTA (n=322) or ExECG (n=240). Primary endpoints were diagnostic performance for ACS, and hospital cost at 30 days. Secondary endpoints were time-to-discharge, admission rates, and downstream resource utilization. RESULTS ACS occurred in 24 (4%) patients. ExECG had 213 negative studies and 27 (26%) positive studies for ACS with sensitivity of 83% [95% CI: 36, 99.6%], specificity of 91% [CI: 86, 94%], and ROC AUC of 0.87 [CI: 0.70, 1]. CCTA (>50% stenosis considered positive) had 288 negative studies and 18/35 (51%) positive studies with a sensitivity of 100% [CI: 81.5, 100], specificity of 94% [CI: 91.2, 96.7%], and ROC of 0.97 [CI: 0.92, 1.0; p=0.2]. Despite CCTA having higher odds of downstream testing (OR 2.0), 30 day per-patient cost was significantly lower for CCTA (

Use of Three-Dimensional Speckle-Tracking Echocardiography for Quantitative Assessment of Global Left Ventricular Function: A Comparative Study to Three-Dimensional Echocardiography

2193 vs

Imaging of Scar in Patients with Ventricular Arrhythmias of Right Ventricular Origin: Cardiac Magnetic Resonance Versus Electroanatomic Mapping

2704, p<0.001). Length of stay for CCTA was significantly reduced (13.5h [95% CI: 11.2-15.7], ExECG 19.7h [95% CI: 17.4-22.1], p<0.0005), which drove the reduction in cost. No patient had post-discharge cardiovascular events at 30 days. CONCLUSIONS CCTA had improved diagnostic performance compared to ExECG, combined with 35% relative reduction in length-of-stay, and 20% reduction in hospital costs. These data lend further evidence that CCTA is useful as a first line assessment in emergency department chest pain.

Improvement after angioplasty and stenting of pulmonary arteries due to sarcoid mediastinal fibrosis.

BACKGROUND The aim of this study was to determine whether global strains derived from three-dimensional (3D) speckle-tracking echocardiography (STE) are as accurate as left ventricular (LV) ejection fraction (LVEF) obtained by two-dimensional (2D) and 3D echocardiography in the quantification of LV function. METHODS Two-dimensional and 3D echocardiography and 2D and 3D STE were performed in 88 patients (LVEF range, 17%-79%). Two-dimensional and 3D global longitudinal strain (GLS), global circumferential strain (GCS), global radial strain, and global area strain were quantified and correlated with LV function determined by 2D and 3D echocardiographic LVEF. Reproducibility, feasibility, and duration of study to perform 3D STE were assessed by independent, blinded observers. RESULTS A total of 78 patients (89%) underwent 3D STE. All 3D speckle-tracking echocardiographic parameters had strong correlations with assessment of LV function determined by 2D and 3D echocardiographic LVEF. Three-dimensional GCS was the best marker of LV function (r = -0.89, P < .0001). Subgroup analysis demonstrated that 3D speckle-tracking echocardiographic parameters were particularly useful in identifying LV dysfunction (LVEF < 50%). Receiver operating characteristic curve analysis demonstrated areas under the curve of 0.97 for 3D GCS, 0.96 for 3D global radial strain, 0.95 for 3D global area strain, and 0.87 for 3D GLS. An optimal 3D GCS cutoff value of magnitude < -12% predicted LV dysfunction (LVEF obtained by 2D echocardiography < 50%) with 92% sensitivity and 90% specificity. There was good correlation between 2D GLS and 3D GLS (r = 0.85, P < .001; mean difference, -1.7 ± 6.5%). Good intraobserver, interobserver, and test-retest agreements were seen with 3D STE. Time for image acquisition to postprocessing analysis was significantly reduced with 3D STE (3.7 ± 1.0 minutes) compared with 2D STE (4.6 ± 1.5 min) (P < .05). CONCLUSIONS Global strain by 3D STE is a promising novel alternative to quantitatively assess LV function. Three-dimensional STE is reproducible, feasible, and time efficient.

Reproducibility of Regional and Global Longitudinal Strains Derived from Two-Dimensional Speckle-Tracking and Doppler Tissue Imaging between Expert and Novice Readers during Quantitative Dobutamine Stress Echocardiography

Imaging of Scar in Patients with RV Origin Arrhythmias: CMR Versus EAM. Introduction: Assessment of late gadolinium enhancement (LGE) at cardiac magnetic resonance is often used to detect scar in patients with arrhythmias of right ventricular (RV) origin. Recently, electroanatomic mapping (EAM) has been shown to reliably detect scars corresponding to different cardiomyopathic substrates. We compared LGE with EAM for the detection of scar in patients with arrhythmias of RV origin.

The role of 3D transesophageal echocardiography during percutaneous closure of paravalvular mitral regurgitation

We describe a series of cases referred to our institution with working diagnoses of chronic thrombo-embolic pulmonary hypertension (CTEPH) for consideration of surgical pulmonary thrombo-endarterectomy (PTE). Investigations in two cases revealed extrinsic compression of the pulmonary arteries from massive mediastinal lymphadenopathy (mediastinal fibrosis) due to underlying sarcoidosis. Angioplasty and stenting of the pulmonary arteries were performed in all cases with sustained haemodynamic and functional improvement. This highlights the value of new imaging modalities in delineating causes of pulmonary hypertension, and demonstrates an interventional approach for selected cases.

Contrast transoesophageal echocardiography remains superior to contrast-enhanced cardiac magnetic resonance imaging for the diagnosis of patent foramen ovale

BACKGROUND Longitudinal strain (LS) is a quantitative parameter that adds incremental value to wall motion analysis. The aim of this study was to compare the reproducibility of LS derived from Doppler tissue imaging and speckle-tracking between an expert and a novice strain reader during dobutamine stress echocardiography (DSE). METHODS Forty-one patients (mean age, 65 ± 15 years; mean ejection fraction, 58 ± 11%) underwent DSE per clinical protocol. Global LS derived from speckle-tracking and regional LS derived from both speckle-tracking and Doppler tissue imaging were measured twice by an expert strain reader and also measured twice by a novice strain reader. Intraobserver and interobserver analyses were performed using intraclass correlation coefficients (ICC), Bland-Altman analysis, and absolute difference values (mean ± SD). RESULTS Global LS measured by the expert strain reader demonstrated high intraobserver measurement reproducibility (rest: ICC = 0.95, absolute difference = 5.5 ± 4.9%; low dose: ICC = 0.96, absolute difference = 5.7 ± 3.7%; peak dose: ICC = 0.87, absolute difference = 11.4 ± 8.4%). Global LS measured by the novice strain reader also demonstrated high intraobserver reproducibility (rest: ICC = 0.97, absolute difference = 4.1 ± 3.4%; low dose: ICC = 0.94, absolute difference = 5.4 ± 5.9%; peak dose: ICC = 0.94, absolute difference = 6.1 ± 4.8%). Global LS also showed high interobserver agreement between the expert and novice readers at all stages of DSE (rest: ICC = 0.90, absolute difference = 8.5 ± 7.5%; low dose: ICC = 0.90, absolute difference = 8.9 ± 7.1%; peak dose: ICC = 0.87, absolute difference = 10.8 ± 8.4%). Of all parameters studied, LS derived from Doppler tissue imaging had relatively low interobserver and intraobserver agreement. CONCLUSIONS Global LS is highly reproducible during all stages of DSE. This variable is a potentially reliable and reproducible measure of myocardial deformation.

Cardiac Computed Tomography—Evidence, Limitations and Clinical Application

paravalvular mitral regurgitation (mr) after mitral valve replacement may lead to heart failure and hemolysis. There are data to suggest that closure of paravalvular mitral regurgitant leaks confers an improved prognosis, with reduced hemolysis and improved functional status ([1][1]). These patients

Early and Late Cardiac Perforation by Amplatzer Atrial Septal Defect and Patent Foramen Ovale Devices

AIMS In 30-40% of patients with acute ischaemic stroke, the cause remains undefined (cryptogenic stroke). Contrast transoesophageal echocardiography (TEE) is considered the gold standard for patent foramen ovale (PFO) detection. Recently, however, cardiac magnetic resonance (CMR) has also been applied to detect PFO. In this study, we compared the diagnostic value of CMR and TEE in detecting PFO in a group of patients with apparently cryptogenic stroke. METHODS AND RESULTS Twenty-five patients (age 50 ± 13 years, 16 males) with apparently cryptogenic ischaemic stroke underwent contrast-enhanced TEE and contrast CMR for detection of possible PFO. Both imaging studies were performed during Valsalva manoeuvre. PFO grading results were assessed visually both for TEE and for CMR, according to the entity of contrast passage in the left atrium (grade 0 = no PFO; grades 1, 2, and 3 = mild, medium, and wide PFO, respectively). TEE detected PFO in 16 patients (64%). Contrast-enhanced CMR identified a PFO in 7 (44%) of these patients. TEE showed a grade 1 PFO in five patients, a grade 2 PFO in eight patients, and a grade 3 PFO in three patients. Of these patients, CMR failed to identify PFO in all five patients with a grade 1 PFO, in one patient with a grade 2 PFO, and one patient with grade 3 PFO according to TEE. None of the nine patients without PFO at TEE was shown to have a PFO at CMR. When compared with TEE, the present methodology of CMR had a sensitivity of 50%, specificity of 100%, negative predictive value of 31%, and a positive predictive value of 100%. CONCLUSION Our data suggest that TEE is the cornerstone imaging diagnostic test to detect and characterize PFO in patients with ischaemic stroke, and is shown to be better compared with the current CMR sequences.