Carmen C. Beladan

Left atrial dysfunction as a correlate of heart failure symptoms in hypertrophic cardiomyopathy.

BACKGROUND Hypertrophic cardiomyopathy (HCM) represents a generalized myopathic process affecting both ventricular and atrial myocardium. We aimed to assess left atrial (LA) function by two-dimensional speckle tracking echocardiography and its relation with left ventricular (LV) function and clinical status in patients with HCM. METHODS We prospectively enrolled 37 consecutive patients with HCM and 37 normal subjects with similar age and gender distribution. Longitudinal LV strain (ε) and LA ε and strain rate (Sr) parameters (systolic, early diastolic, and late diastolic during atrial contraction) were assessed. RESULTS Peak LAε and LA Sr parameters were significantly lower in patients compared with controls (P ≤ .001 for all). In patients, all LA function parameters correlated with LVε (P < .003 for all). Indexed LA volume, LA function parameters, and mitral regurgitation degree were the main correlates of New York Heart Association class; late diastolic strain rate during atrial contraction was the only independent predictor of symptomatic status. CONCLUSION In patients with HCM, LA function is significantly reduced and related to LV dysfunction. Moreover, LA booster pump function emerged as an independent correlate of heart failure symptoms in this setting.

Left ventricular remodelling and torsional dynamics in dilated cardiomyopathy: reversed apical rotation as a marker of disease severity

Decreased left ventricular (LV) rotation and torsion and even reversed systolic apical rotation have been described in patients with dilated cardiomyopathy (DCM). We sought to test in patients with DCM whether reversed apical rotation with loss of LV torsion is related to the extent of LV remodelling and to the severity of LV dysfunction.

Left atrial remodelling early after mitral valve repair for degenerative mitral regurgitation

Objective: Left atrial (LA) size is an important predictor of outcome after mitral valve replacement in patients with symptomatic chronic mitral regurgitation (MR). Data on LA remodelling after mitral valve repair (MVr) for chronic non-ischaemic MR are scarce. The aim of this study was to assess changes in LA size early after MVr for chronic severe degenerative MR and to identify clinical and echocardiographic correlates of those changes. Methods: The study analysed 225 consecutive patients who underwent MVr and were echocardiographically evaluated in our hospital within 1 month before and 1–6 months after surgery. Patients with MR aetiology other than degenerative, associated aortic valve replacement, or congenital heart disease were excluded. The remaining 79 patients (aged 60 (SD 12) years, 55 men) with isolated chronic severe degenerative MR formed the study group. LA reverse remodelling was defined as a decrease in LA volume index (LAVi) ⩾15%. Results: LA dimensions significantly decreased after MVr (p<0.001). Mean LAVi reduction was 29% (SD 18%). LA reverse remodelling was observed in 63 patients (80%). Correlates of LAVi reduction were preoperative LAVi (p = 0.008), systolic and diastolic blood pressure (p = 0.032, p = 0.009), postoperative transmitral mean pressure gradient (p = 0.001) and residual MR (p = 0.043). LAVi reduction was lower in patients >45 years (p = 0.008) and in hypertensive patients (p = 0.031). Conclusion: LA reverse remodelling is common early after MVr for chronic severe degenerative MR. Preoperative LAVi, blood pressure, postoperative transmitral mean pressure gradient, residual MR and age >45 are related to LAVi reduction. The prognostic value of LA reduction in this setting needs further study.

Prognostic Role of Left Atrial Volume in Elderly Patients with Symptomatic Stable Chronic Heart Failure: Comparison with Left Ventricular Diastolic Dysfunction and B-Type Natriuretic Peptide

Background: Left atrial (LA) volume and B‐type natriuretic peptide (BNP) represent powerful outcome predictors in patients with heart failure (HF). Aim: To assess the comparative prognostic role of LA volume (indexed to body surface area, LAVi), left ventricular diastolic dysfunction (LVDD) and BNP levels on long‐term outcome in patients with symptomatic but stable chronic HF. Methods: We studied consecutively 46 patients with symptomatic stable chronic HF (73 ± 10 years, 30 men), in sinus rhythm, without significant valvular disease. Echocardiographic measurements included: LV mass, LV volumes and ejection fraction, and LAVi. LVDD was graded using a comprehensive Doppler algorithm. Blood taken before echocardiography was assayed for BNP levels. Primary end point was combined: all‐cause mortality and hospitalization for worsening HF. Results: During 20 ± 14 months of follow‐up 19 events occurred: 8 deaths, and 11 hospitalizations for HF. In univariate analyses LAVi, LVDD, BNP levels, LV ejection fraction, LV volumes, and LV mass were significant outcome predictors (P < 0.05). At multivariate regression LAVi was the only independent predictor of outcome (hazard ratio: 1.03 per 1 ml/m2 increase, 95% CI: 1.01–1.06, P = 0.02). Conclusion: Although directly related to LVDD and to BNP levels, only LAVi emerged as an independent outcome predictor in this cohort of elderly patients with symptomatic stable chronic HF.

Echo-Tracking Assessment of Carotid Artery Stiffness in Patients with Aortic Valve Stenosis

Background: There is little information about mechanical properties of large arteries in patients (pts) with aortic stenosis (AS). Methods: Nineteen patients with AS (aortic valve area: 0.88 ± 0.29 cm2) and 24 control subjects without AS but with a similar distribution of risk factors were recruited. β index, pressure‐strain elastic modulus (Ep), arterial compliance (AC), augmentation index (AIx), and local pulse‐wave velocity (PWV) were obtained at the level of right common carotid artery (CCA) by a real time echo‐tracking system. Time to dominant peak of carotid diameter change waveform, corrected for heart rate (tDPc), and maximum rate of rise of carotid diameter (dD/dt) were measured. Systemic arterial compliance (SAC) was also calculated. Parameters of AS severity (mean gradient, valve area, stroke work loss [SWL]) were determined. Results: tDPc was higher in patients with AS than in controls (7.9 ± 0.6 vs. 6.6 ± 0.7, P < 0.0001) while dD/dt was lower (5.3 ± 3.6 mm/s vs. 7.8 ± 2.8 mm/s, P = 0.01). AIx was significantly higher in AS group (32.5 ± 13.6% vs. 20.6 ± 12.2%, P = 0.005) and had a linear correlation both with tDPc (r = 0.63, P < 0.0001) and with dD/dt (r =−0.38, P = 0.01). There was a significant correlation between carotid AC and SAC (r = 0.49, P = 0.03), but only carotid AC was related to SWL (r = 0.51, P = 0.02), while SAC was not (P = 0.26).Conclusions: AIx was the only parameter of arterial rigidity found to be higher in patients with AS than in controls. Carotid AC showed a significant correlation with SAC and it seemed to be more closely related to AS severity than to SAC.

Respiratory maneuvers in echocardiography: a review of clinical applications

During echocardiographic examination, respiration induces cyclic physiological changes of intracardiac haemodynamics, causing normal variations of the right and left ventricle Doppler inflows and outflows and physiological variation of extracardiac flows. The respiration related hemodynamic variation in intra and extracardiac flows may be utilized in the echocardiography laboratory to aid diagnosis in different pathological states. Nevertheless, physiologic respiratory phases can cause excessive translational motion of cardiac structures, lowering 2D image quality and interfering with optimal Doppler interrogation of flows or tissue motion.This review focuses on the impact of normal respiratory cycle and provocative respiratory maneuvers in echocardiographic examination, both in physiological and pathological states, emphasizing their applications in specific clinical situations.

The left ventricle in aortic stenosis - imaging assessment and clinical implications

Aortic stenosis has an increasing prevalence in the context of aging population. In these patients non-invasive imaging allows not only the grading of valve stenosis severity, but also the assessment of left ventricular function. These two goals play a key role in clinical decision-making. Although left ventricular ejection fraction is currently the only left ventricular function parameter that guides intervention, current imaging techniques are able to detect early changes in LV structure and function even in asymptomatic patients with significant aortic stenosis and preserved ejection fraction. Moreover, new imaging parameters emerged as predictors of disease progression in patients with aortic stenosis. Although proper standardization and confirmatory data from large prospective studies are needed, these novel parameters have the potential of becoming useful tools in guiding intervention in asymptomatic patients with aortic stenosis and stratify risk in symptomatic patients undergoing aortic valve replacement.This review focuses on the mechanisms of transition from compensatory left ventricular hypertrophy to left ventricular dysfunction and heart failure in aortic stenosis and the role of non-invasive imaging assessment of the left ventricular geometry and function in these patients.

Atrioventricular Block in the Elderly: Does Echocardiography Hold the Key?

![Figure][1] ![Figure][1] [![Graphic][3] ][3] ![Figure][1] [![Graphic][4] ][4] ![Figure][1] [![Graphic][5] ][5] ![Figure][1] [![Graphic][6] ][6] ![Figure][1] [![Graphic][7] ][7] An 80-year-old man presented with

Images in cardiology. Atrioventricular block in the elderly: does echocardiography hold the key?

![Figure][1] ![Figure][1] [![Graphic][3] ][3] ![Figure][1] [![Graphic][4] ][4] ![Figure][1] [![Graphic][5] ][5] ![Figure][1] [![Graphic][6] ][6] ![Figure][1] [![Graphic][7] ][7] An 80-year-old man presented with

A Paravertebral Pulsatile Mass

A 46-year–old man was admitted for severe back pain over the interscapular area radiating anteriorly along the ribs. Symptoms started intermittently 2 months previously, but became severe and persistent over the past 3 days. The patient was a former sailor and a heavy smoker, with no relevant personal or family history of cardiovascular disease. At physical examination, a pulsatile left paravertebral mass could be seen and palpated close to the spine (online-only Data Supplement Movie I). A high-pitched descrescendo diastolic murmur could be heard along the left sternal border. He was normotensive and tachycardic, with no signs of pulmonary or systemic congestion. The ECG showed sinus tachycardia (115 beats per minute) and complete right bundle-branch block with secondary ST-T …