Davide Ermacora

Age-, Body Size-, and Sex-Specific Reference Values for Right Ventricular Volumes and Ejection Fraction by Three-Dimensional Echocardiography A Multicenter Echocardiographic Study in 507 Healthy Volunteers

Background— Right ventricular (RV) volumes and ejection fraction (EF) vary significantly with demographic and anthropometric factors and are associated with poor prognosis in several cardiovascular diseases. This multicenter study was designed to (1) establish the reference values for RV volumes and EF using transthoracic three-dimensional (3D) echocardiography; (2) investigate the influence of age, sex, and body size on RV anatomy; (3) develop normative equations. Methods and Results— RV volumes (end-diastolic volume and end-systolic volume), stroke volume, and EF were measured by 3D echocardiography in 540 healthy adult volunteers, prospectively enrolled, evenly distributed across age and sex. The relation of age, sex, and body size parameters was investigated using bivariate and multiple linear regression. Analysis was feasible in 507 (94%) subjects (260 women; age, 45±16 years; range, 18–90). Age, sex, height, and weight significantly influenced RV volumes and EF. Sex effect was significant (P<0.01), with RV volumes larger and EF smaller in men than in women. Older age was associated with lower volumes (end-diastolic volume, −5 mLdecade; end-systolic volume, −3 mL/decade; EF, −2 mL/decade) and higher EF (+1% per decade). Inclusion of body size parameters in the statistical models resulted in improved overall explained variance for volumes (end-diastolic volume, R 2=0.43; end-systolic volume, R 2=0.35; stroke volume, R 2=0.30), while EF was unaffected. Ratiometric and allometric indexing for age, sex, and body size resulted in no significant residual correlation between RV measures and height or weight. Conclusions— The presented normative ranges and equations could help standardize the 3D echocardiography assessment of RV volumes and function in clinical practice, considering the effects of age, sex, and body size.

Validation of a novel automated border-detection algorithm for rapid and accurate quantitation of left ventricular volumes based on three-dimensional echocardiography

AIMS To assess the accuracy and reproducibility of a novel automated software for left ventricular (LV) volumes and ejection fraction (EF) measurements using real-time three-dimensional echocardiography (3DE). METHODS AND RESULTS A total of 103 patients with a wide range of LV volumes were analyzed with both 4D AutoLVQ and 4D TomTec software. In 23 patients, a side-by-side comparison of LV volume and EF measurements was done between 3DE, 2DE, and cardiac magnetic resonance (CMR). Excellent correlation was found between 4D AutoLVQ and 4D TomTec [r = 0.98 for end-diastolic volume (EDV), 0.99 for end-systolic volume (ESV), and 0.97 for EF, P < 0.0001], with small biases and narrow limits of agreement: EDV 5.2 mL (-14 to 25 mL), ESV 2.9 mL (-10 to 16 mL), EF -0.2% (-7 to 6%). Time of analysis was halved using 4D AutoLVQ with manual correction (1 min 52 s+/- 30 s) in comparison with 4D TomTec software (3 min 46 s +/- 1 min 24 s). Both softwares showed similar accuracy in comparison with CMR (4D AutoLVQ biases -11.0 mL, -9.1 mL, and 2.9%; 4D TomTec biases -8.3 mL, -7.4 mL, and 2.8% for EDV, ESV, and EF, respectively, P = NS for all) and good reproducibility. CONCLUSION Novel 4D AutoLVQ software showed very good agreement with more time-consuming 4D TomTec software, having similar accuracy against CMR.

High Volume-Rate Three-Dimensional Stress Echocardiography to Assess Inducible Myocardial Ischemia: A Feasibility Study

BACKGROUND Compared with previous three-dimensional (3D) echocardiographic scanners, high-volume rate scanners allow higher temporal resolution and the possibility of displaying cropped images side by side. These new features make 3D echocardiography (3DE) even more attractive for application during stress. The aim of this study was to compare the feasibility and diagnostic accuracy of high-volume rate 3DE with state-of-the-art two-dimensional echocardiography (2DE) in detecting ischemia during dipyridamole-induced stress (DipSE). METHODS One hundred seven consecutive patients with known or suspected coronary artery disease were examined using 2DE and 3DE during the same DipSE examination. RESULTS Seventeen patients with inadequate images on 2DE requiring contrast infusion and 6 patients with inadequate detection of the endocardial borders on 3DE were excluded (feasibility of 3DE, 79%). The diagnostic accuracy of 3DE with DipSE was tested in the remaining 84 patients. Both acquisition time (65 +/- 30 s vs 16 +/- 3 seconds, respectively; P < .0001) and analysis time (176 +/- 63 vs 91 +/- 5 seconds, respectively; P < .0001) were significantly longer with 2DE than 3DE. Temporal resolution was significantly higher with 2DE than 3DE (75 +/- 5 frames/s vs 41 +/- 5 volumes/s, respectively; P < .0001). The wall motion score index (WMSI) at baseline was similar with 2DE and 3DE (1.041 +/- 0.023 vs 1.049 +/- 0.01, respectively; P = NS). In contrast, peak stress WMSI was significantly lower with 2DE than 3DE (1.21 +/- 0.025 vs 1.29 +/- 0.023, respectively; P = .011). In particular, mean apical peak stress WMSI was significantly lower with 2DE than 3DE (1.34 +/- 0.057 vs 1.55 +/- 0.078, respectively; P < .0001). In the 44 patients who underwent coronary angiography, the overall accuracy of 3DE was similar to that of 2DE (sensitivity, 80% vs 78%; specificity, 87% vs 91%). In the left anterior descending coronary artery territory, for which 3DE showed higher WMSI values, the sensitivity of 3DE was significantly higher than that of 2DE (87% vs 78%, P = .011), while specificity was similar. CONCLUSIONS Three-dimensional echocardiography with DipSE is feasible and offers shorter acquisition and analysis times compared with 2DE, with similar overall diagnostic accuracy. However, the ability of 3DE to identify wall motion abnormalities in the apical region explains its higher sensitivity for the left anterior descending coronary artery territory.

Role of Three‐Dimensional Echocardiography in Structural Complications after Acute Myocardial Infarction

Three‐dimensional echocardiography (3DE) is a unique cardiovascular imaging modality in terms of: ability to provide realistic anatomical views of cardiac structures in the beating heart and possibility to visualize cardiac structures from any desired perspective. Therefore, 3DE is emerging as an accurate imaging modality for a prompt diagnosis and detailed anatomical description of structural complications (SC) of acute myocardial infarction (AMI). We report 3 emblematic cases which show how both the transthoracic (TTE) and transesophageal (TEE) 3D imaging can provide precise anatomic information useful to address management of SC in AMI patients: (1) detailed assessment of size, location, and morphology of an apical ventricular septal defect (VSD) obtained with 3DTTE was pivotal in referring the patient to percutaneous closure of it; (2) size and location of a complex inferior VSD with irregular margins advised against percutaneous closure; and (3) 3DTEE assisted surgeons to choose between reparative or replacement surgery for an acute mitral regurgitation due to complete papillary muscle rupture.

Transthoracic three-dimensional echocardiography visualization of functional anatomy of double-orifice mitral valve

A 14-year-old boy was referred to our echocardiography laboratory because of a recent history of palpitations. Both physical examination and ECG were unremarkable. An ambulatory ECG recording detected only rare supraventricular ectopic beats. A two-dimensional transthoracic echocardiogram (2DE, Panel A , …

An unusual acute coronary syndrome: undisclosed disease hidden under a confounding clinical presentation

A 65-year-old man presented to our Emergency Unit with a history of chest pain of 12 h duration. The pain was dull, non-exertional, and also involved the epigastric and umbilical regions. Other review of systems was unremarkable. He reported similar episodes of chest discomfort lasting a few minutes, and associated with weakness in the prior few days. The prompt resolution of the symptoms caused him to underestimate the importance of these symptoms. Past medical history was negative for cardiopulmonary disease. There were no cardiovascular risk factors other than smoking. He took no medications. On admission, the patient was in no acute distress. Vital signs were blood pressure 110/60 mmHg, heart rate 104 beats/min, regular in rate and rhythm, oxygen saturation 99%. The jugular venous pressure (JVP) was not elevated, and there was no pulsus paradoxsus. Auscultation of the heart and lungs was unremarkable. Examination of other systems was normal; peripheral arterial pulses were present. The electrocardiogram (EKG) showed a normal sinus rhythm, ST-segment depression and T-wave inversion in anterior and lateral leads, and left ventricular hypertrophy. Laboratory tests were as follows: Troponin I 7.48 lg/L (normal reference range 0.00–0.15 lg/L), myoglobin 137 lg/L (normal reference range 12–70 lg/L), D-dimer 984 lg/L (normal reference range \225 lg/L) and NTproBNP 2,972 ng/L (normal reference range 0–900 ng/L). The chest X-ray study showed normal lung fields, with a normal cardiac silhouette and mediastinum. On the basis of clinical picture, the EKG, and the laboratory panel, an initial diagnosis of anterolateral non-ST elevated myocardial infarction was suggested. Because the patient also complained of abdominal pain, on abdominal physical examination, an unexpected finding at the auscultation was a continuous bruit in the periumbilical region. Therefore, an alternative diagnosis was hypothesized: aortic dissection with proximal involvement of a coronary ostium. An emergency abdominal echography was thus performed, and it showed an aortic aneurysm with a large communication to the inferior vena cava. Color Doppler confirmed this finding with the evidence of a turbulent continuous blood flow from aorta to vena cava through this patency. To better define this finding, a contrast-enhanced abdominal computed tomography (CT scan) was performed that revealed: an aneurysm of the descending aorta extending from the renal arteries to the iliac bifurcation, with parietal thrombosis and calcifications; a large aorto-caval fistula (ACF) just above the iliac bifurcation; and a thromboembolic occlusion of the segmentary branches of the pulmonary artery. The patient underwent an emergency aorto-iliac bypass, and a prosthetic graft from the left bypass branch to the common femoral artery. In the intensive care unit, he was treated with intravenous nitrates and fenoldopam, and started on ACE inhibitors. The postoperative course was characterized by a progressive amelioration of the clinical picture. Laboratory studies returned to normal. Subsequent cardiac monitoring revealed a normalization of the ST-segment depression and T wave inversion. Echocardiography showed a mildly dilated left ventricle (EDV 75 ml/m 2 ), preserved ejection fraction (53%), mild hypertrophy