Ellen Ostenfeld

Manual correction of semi-automatic three-dimensional echocardiography is needed for right ventricular assessment in adults; validation with cardiac magnetic resonance

BackgroundThree-dimensional echocardiography (3DE) and semi-automatic right ventricular delineation has been proposed as an appropriate method for right ventricle (RV) evaluation. We aimed to examine how manual correction of semi-automatic delineation influences the accuracy of 3DE for RV volumes and function in a clinical adult setting using cardiac magnetic resonance (CMR) as the reference method. We also examined the feasibility of RV visualization with 3DE.Methods62 non-selected patients were examined with 3DE (Sonos 7500 and iE33) and with CMR (1.5T). Endocardial RV contours of 3DE-images were semi-automatically assessed and manually corrected in all patients. End-diastolic (EDV), end-systolic (ESV) volumes, stroke volume (SV) and ejection fraction (EF) were computed.Results53 patients (85%) had 3DE-images feasible for examination. Correlation coefficients and Bland Altman biases between 3DE with manual correction and CMR were r = 0.78, -22 ± 27 mL for EDV, r = 0.83, -7 ± 16 mL for ESV, r = 0.60, -12 ± 18 mL for SV and r = 0.60, -2 ± 8% for EF (p < 0.001 for all r-values). Without manual correction r-values were 0.77, 0.77, 0.70 and 0.49 for EDV, ESV, SV and EF, respectively (p < 0.001 for all r-values) and biases were larger for EDV, SV and EF (-32 ± 26 mL, -21 ± 15 mL and - 6 ± 9%, p ≤ 0.01 for all) compared to manual correction.ConclusionManual correction of the 3DE semi-automatic RV delineation decreases the bias and is needed for acceptable clinical accuracy. 3DE is highly feasible for visualizing the RV in an adult clinical setting.

Combined preoperative information using a bullseye plot from speckle tracking echocardiography, cardiac CT scan, and MRI scan: targeted left ventricular lead implantation in patients receiving cardiac resynchronization therapy

AIMS To evaluate the feasibility and incremental value of using an integrated bullseye model for presenting data from cardiac computed tomography (CT) and magnetic resonance imaging (MRI) in combination with echocardiography evaluation of segmental mechanical delay for guiding optimal left ventricular lead placement in cardiac resynchronization therapy (CRT). METHODS AND RESULTS Thirty-nine patients (69 ± 9.7 years, 77% male, 82% with LBBB, 54% with ischaemic cardiomyopathy, 82% New York Heart Association classification of heart failure III) eligible for CRT were included. The left ventricular segment with the latest mechanical activation was determined by echocardiography with speckle tracking radial strain. Cardiac CT scan was used for anatomical evaluation of the coronary sinus and its branches. Cardiac MRI was used for evaluation of viability. A composite bullseye plot was constructed, indicating the most appropriate site for left ventricle (LV) lead placement. The latest mechanical delay was in the basal-anterior (3%), basal-inferior (3%), basal-inferolateral (13%), basal-anterolateral (21%), mid-anterior (8%), mid-inferior (3%), mid-inferolateral (34%), and mid-anterolateral (16%) segment. There were on average 2.5 ± 0.8 veins of suitable sizes (≥1.5 mm in diameter). A preoperative combined bullseye plot indicated that in 53% of the patients, there was a matching vein in the segment with the latest mechanical delay. If immediately adjacent segments were included, an optimal placement was possible in 95% of the patients. At 6 months, there was a statistically significant reduction in the left ventricular end systolic volume and the left ventricular ejection fraction was improved (P < 0.01). CONCLUSION Presenting data from echocardiography, cardiac CT, and MRI in a combined bullseye plot is both feasible and convenient for indicating the most appropriate site for LV lead placement. An optimal electrode position can be suggested in almost all patients.

Assessment of right ventricular volumes and ejection fraction by echocardiography: from geometric approximations to realistic shapes

Right ventricular volumes and ejection fraction are challenging to assess by echocardiography, but are well established as functional and prognostic parameters. Three-dimensional (3D) echocardiography has become widespread and relatively easy to use, making calculation of these parameters feasible in the large majority of patients. We review past attempts to estimate right ventricular volumes, current strengths and weaknesses of 3D echocardiography for this task, and compare with corresponding data from magnetic resonance imaging.

A comparison between radial strain evaluation by speckle-tracking echocardiography and cardiac magnetic resonance imaging, for assessment of suitable segments for left ventricular lead placement in cardiac resynchronization therapy.

AIMS A cut-off of 9.8% maximum speckle-tracking radial strain in the segment with the latest mechanical delay has been proposed as predictive for selecting the best left ventricular lead placement for positive response on cardiac resynchronization therapy (CRT). However, pacing transmural scar should be avoided, and the purpose of this study was to evaluate the ability of echocardiographic radial strain to predict the presence of scar in the left ventricle segments. METHODS AND RESULTS A total of 404 left ventricular segments were analysed, from 34 patients eligible for CRT. Pre-operative cardiac magnetic resonance (CMR) and echocardiography were performed, and maximal strain values from echocardiography speckle tracking were compared with CMR data. Hypokinesia and strain values showed a strong correlation (P < 0.001). Even though segments with CMR-verified scar had lower strain values than segments without scar (14.8 ± 7 vs. 16.0 ± 10), the predictive value of the proposed 9.8% cut-off was low (sensitivity 33% and specificity 72%). Scar burden was higher in ischaemic patients (13.5 vs. 5.3% P = 0.0001). Relative difference in strain values (target segment strain compared with the average strain value of the adjacent segments) was higher if there was transmural scar in the target segment as compared with a hypokinetic but viable target segment (87 vs. 38% difference, P = 0.03). CONCLUSION Speckle tracking radial strain should ideally be complemented by CMR for accurate assessment of viability, especially for patients with ischaemic aetiology of heart failure where transmural scar is more common. Comparison of strain values with the adjacent segments may be helpful for assessing viability.

Comparison of different views with three-dimensional echocardiography: apical views offer superior visualization compared with parasternal and subcostal views

Studies seeking to validate real‐time three‐dimensional echocardiography (3DE) with regard to cardiac function and dimensions have almost exclusively used apical views. However, it has never been examined whether apical views are preferable to parasternal or subcostal views. In the present study, we compared the feasibility of 3DE volumetric measurements of the four heart chambers in three different views. We included 40 patients planned for a routine two‐dimensional transthoracic echocardiography examination (2DE). All patients were scanned with both 2DE and 3DE (Sonos 7500; Philips Medical Systems Andover, MA, USA). Parasternal, apical and subcostal views were used for 3DE. Volumes were calculated using manual tracing in 16 planes. 2DE was performed in parasternal longaxis, subcostal and apical four‐ and two‐chamber views. Manual tracing was used for area calculations. To be judged fully traceable, 5/6 (85%) or more of the ventricular and atrial walls had to be adequately visualized in each plane. The left ventricle and left atrium were adequately visualized in the 3DE apical view in 34 (85%) and 40 (100%) patients, respectively. Visualization of the right atrium was adequate in 31 (78%) patients, whereas the right ventricle was adequately visualized in only 12 (30%) patients. The apical view of 3DE provided superior visualization of all four heart chambers compared with the parasternal and subcostal views, when applying a slight off‐axis approach for both ventricles when needed. Thus, in the present study, there was no incremental value of assessment of chamber volumes in the parasternal and subcostal views.

Imaging the right heart pulmonary circulation unit: Insights from advanced ultrasound techniques

The right heart pulmonary circulation unit (RH‐PCU) is a key determinant of prognosis in several cardiorespiratory diseases. Although right heart catheterization is considered the gold standard for pulmonary hemodynamic assessment, a comprehensive cardiovascular ultrasound approach is an essential step in the diagnostic–prognostic clinical pathway of patients with suspect or overt pulmonary hypertension. The exponential development of advanced ultrasound techniques (strain, 3‐dimensional echocardiography and lung ultrasound) has led to new insights into the evaluation of RH‐PCU structure and function, overcoming some limitations of standard Doppler echocardiography. In the near future, exercise Doppler echocardiography may become a useful technique for detecting a latent stage of pulmonary hypertension and for evaluating right ventricular contractile reserve.

Discriminatory ability of right atrial volumes with two- and three-dimensional echocardiography to detect elevated right atrial pressure in pulmonary hypertension

Pulmonary hypertension (PH) patients have high mortality due to right ventricular failure. Predictors of poor prognostic outcome are increased right atrial volume (RAV) and elevated mean right atrial pressure (mRAP). Our aim was to determine whether RAV measured with 2D echocardiography (2DE) and 3D echocardiography (3DE) can detect elevated mRAP in patients evaluated for PH.

Imaging the Right Heart-Pulmonary Circulation Unit : The Role of MRI and Computed Tomography

The different components of the right heart pulmonary circulation unit can be investigated by MRI and computed tomography. MRI has clear advantages over echocardiography for accurate definition of right heart function and structure and to derive functional information regarding the pulmonary vasculature. Computed tomography is superior for the assessment of parenchymal and vascular pathologies of the lung with indications in the diagnostic work-up of pulmonary hypertension, but with more limited capability to evaluate right ventricular function and in deriving pulmonary hemodynamics. Recent technical developments with these imaging modalities could allow a better evaluation of the right heart pulmonary circulation unit.

The Right Heart International Network (RIGHT-NET) : Rationale, Objectives, Methodology, and Clinical Implications

The Right Heart International Network is a multicenter international study aiming to prospectively collect exercise Doppler echocardiography tests of the right heart pulmonary circulation unit (RHPCU) in large cohorts of healthy subjects, elite athletes, and individuals at risk of or with overt pulmonary hypertension. It is going to provide standardization of exercise stress echocardiography of RHPCU and explore the full physiopathologic response.

Increased right atrial volume measured with cardiac magnetic resonance is associated with worse clinical outcome in patients with pre-capillary pulmonary hypertension: RAV in patients with pre-capillary pulmonary hypertension

Pre‐capillary pulmonary hypertension (PHpre‐cap) has a poor prognosis, especially when caused by pulmonary arterial hypertension (PAH) associated with systemic sclerosis (SSc‐PAH). Whether cardiac magnetic resonance (CMR)‐based quantification of atrial volumes in PHpre‐cap is beneficial in risk assessment is unknown. The aims were to investigate if (i) atrial volumes using CMR are associated with death or lung transplantation in PHpre‐cap, (ii) atrial volumes differ among four unmatched major PHpre‐cap subgroups, and (iii) atrial volumes differ between SSc‐PAH and idiopathic/familial PAH (IPAH/FPAH) when matched for pulmonary vascular resistance (PVR).