Fen-Chiung Lin

Prognostic value of LA volumes assessed by transthoracic 3D echocardiography: comparison with 2D echocardiography.

OBJECTIVES The hypothesis of this study was that minimal left atrial volume index (LAVImin) by 3-dimensional echocardiography (3DE) is the best predictor of future cardiovascular events. BACKGROUND Although maximal left atrial volume index (LAVImax) by 2-dimensional echocardiography (2DE) is a robust index for predicting prognosis, the prognostic value of LAVImin and the superiority of measurements by 3DE over 2DE have not been determined in a large group of patients. METHODS In protocol 1, we assessed age and sex dependency of LAVIs using 2DE and 3DE in 124 normal subjects and determined their cutoff values (mean + 2 SD). In protocol 2, 2-dimensional (2D) and 3-dimensional (3D) LAVImax/LAVImin were measured in 556 patients with high prevalence of cardiovascular disease. After excluding patients with atrial fibrillation, mitral valve disease, and age <18 years, 439 subjects were followed to record major adverse cardiovascular events (MACE). Patients were divided into 2 groups by the cutoff criteria of LAVI in each method. RESULTS In protocol 1, there was no significant age and sex dependency for each 2D and 3D LAVI. In protocol 2, during a mean of 2.5 years of follow-up, MACE developed in 88 patients, including 32 cardiac deaths. Kaplan-Meier survival analyses showed that all 4 LAVI cutoff criteria had significant predictive power of MACE. After variables were adjusted for clinical variables and left ventricular ejection fraction, all 4 methods were still independently and significantly associated with MACE, but 3D-derived LAVImin had the highest risk ratio. 3D LAVImin also had an incremental prognostic value over 3D LAVImax. CONCLUSIONS LAVIs by both 2DE and 3DE are powerful predictors of future cardiac events. 3D LAVImin tended to have a stronger and additive prognostic value than 3D LAVImax.

Effect of Through-Plane and Twisting Motion on Left Ventricular Strain Calculation: Direct Comparison between Two-Dimensional and Three-Dimensional Speckle-Tracking Echocardiography

BACKGROUND The aim of this study was to investigate the effect of out-of-plane motion on discrepancies in strain measurements between two-dimensional (2D) and three-dimensional (3D) echocardiography. METHODS Two-dimensional and 3D data sets were acquired in 54 patients. Using 2D and 3D speckle-tracking software, global circumferential strain (CS) and longitudinal strain (LS) as well as CS and LS at three left ventricular (LV) levels was measured. The effect of through-plane motion was assessed by mitral annular displacement. RESULTS Although a good correlation of global CS was noted between the two methods (r = 0.80, P < .01), mean values of global CS were significantly higher on 3D compared with 2D echocardiography. Correlations of CS and their mean differences were 0.65 and -4.61 at the basal level, 0.76 and -4.17 at the midventricular level, and 0.60 and -2.23 at the apical level, respectively. Correlation of global CS between the two methods was higher in patients who showed mitral annular displacement < 9.4 mm (r = 0.81) compared with those with mitral annular displacement ≥ 9.4 mm (r = 0.61). A good correlation of global LS (r = 0.89, P < .01) was noted, with no significant bias. Correlations of LS and their mean differences were 0.52 and 1.59 at the basal level, 0.89 and -1.17 at the midventricular level, and 0.73 and 1.46 at the apical level, respectively. Correlation of LS between the two methods was higher in patients who showed LV twist < 12.2° (r = 0.94) compared with patients with LV twist ≥ 12.2° (r = 0.68). CONCLUSIONS Through-plane motion produced discrepancies in CS measurements, especially at the LV basal level. Larger bias of LS at the basal and apical LV levels compared with the midventricular level between the two methods suggests that LV twisting also affects the calculation of 2D LS.

Hypothyroid Cardiac Tamponade: Clinical Features, Electrocardiography, Pericardial Fluid and Management

Background:Cardiac tamponade associated with hypothyroidism has been reported, but few studies address the clinical features. This study aims to identify the patient characteristics and to propose a reasonable clinical approach for hypothyroid cardiac tamponade. Method:Patients admitted to Chang Gung Memorial Hospital between September 1998 and September 2008 with pericardial effusion secondary to hypothyroidism were enrolled. Cases involving cardiac tamponade were investigated. The clinical data, electrocardiography, echocardiography and aspirated fluid were examined. Results:Thirty-six patients with moderate or large amount of pericardial effusion as a result of hypothyroidism were examined. Eight patients (22.2%) with both clinical and echocardiographic signs of tamponade were identified and were treated by pericardiocentesis or creation of pleural-pericardial window. These patients were characterized with normal sinus rhythm (80.75 ± 13.45 beats/min), low voltage over limb leads (6 of 8, 75.0%), flat T wave (6 of 8, 75.0%) and clear yellowish pericardial fluid (7 of 8, 87.5%). Their heart rates were significantly lower (80.75 ± 13.45 beats/min versus 112.75 ± 12.87 beats/min, P < 0.01) than those of patients with cardiac tamponade from malignancy, autoimmune disease, tuberculosis and iatrogenic insult. Their interventricular septa were also significantly thicker (15.71 ± 6.70 mm versus 11.70 ± 2.11 mm, P = 0.02). Ten patients (27.8%) had echocardiographic signs of tamponade without paradoxical pulse and were successfully treated with thyroxine without pericardial drainage. Conclusion:For patients diagnosed with cardiac tamponade without sinus tachycardia, hypothyroidism should be highly suspected. Although emergent pericardiocentesis should be performed in clinical cardiac tamponade, patients with echocardiographic tamponade signs without a paradoxical pulse should be treated with thyroxine initially.

Prognostic value of right ventricular ejection fraction assessed by transthoracic 3D echocardiography

Background— Cardiac magnetic resonance is the gold standard for the evaluation of right ventricular (RV) volumes, but it is impractical to perform in every patient. Although reference values of RV volumes and RV ejection fraction by 3D transthoracic echocardiography (3DTTE) have been established, their prognostic values have not been elucidated yet. We hypothesized that RV ejection fraction measured by 3DTTE (3DRVEF) predicts future cardiovascular events. Methods and Results— In protocol 1, we determined the accuracy of RV volumes and RV ejection fraction measurements by 3DTTE against cardiac magnetic resonance in 60 subjects. In protocol 2, 3DRVEF was measured in 446 patients with various cardiovascular diseases. Study subjects were followed up to record cardiac death and major adverse cardiovascular events. In protocol 1, 3DTTE-determined RV end-diastolic volume, end-systolic volume, and RV ejection fraction had good correlations to those by cardiac magnetic resonance (r=0.74–0.90). In protocol 2, 38 cardiac deaths and 88 major adverse cardiovascular events occurred during a median follow-up of 4.1 years. Univariable Cox proportional analysis revealed that 3DRVEF was associated with both cardiac death (P<0.0001) and major adverse cardiovascular event (P<0.0001). 3DRVEF remained as an independent predictor for cardiac death (P<0.0001) and major adverse cardiovascular event (P<0.0001) even in a stepwise multivariable Cox proportional hazard analysis. Classification and regression-tree analysis demonstrated that 3DRVEF played an important role for risk stratification. Conclusions— 3DTTE-determined RV ejection fraction was independently associated with cardiac outcomes in patients with diverse backgrounds. 3DRVEF offered incremental value over clinical risk factors and the other echocardiographic parameters including left ventricular systolic and diastolic function for predicting future adverse outcome.

Long-term outcomes of drug-eluting stents versus bare-metal stents in large coronary arteries

BACKGROUND Long-term (>3 years) outcomes of drug-eluting stents (DES) versus bare-metal stents (BMS) in large coronary arteries were not conclusive. In addition, large coronary vessels were defined using a wide size range (≥3.0 mm) in previous studies. The aim of this study was to assess the long-term efficacy of DES versus BMS in subgroups of different vessel sizes. METHODS A total of 1096 patients (1342 lesions) who underwent either DES or BMS implantation in large coronary vessels was followed for a mean duration of 4.5 years. Patients were divided into 4 subgroups by the reference vessel diameters (Q1: 3.0-3.25 mm, Q2: 3.26-3.50 mm, Q3: 3.51-3.75 mm, and Q4: 3.76-4.50 mm). The primary endpoint was major adverse cardiac events (MACE), defined as a composite of cardiac death, myocardial infarction, target vessel revascularization, and stent thrombosis. The propensity score-adjusted Cox regression method was applied. RESULTS In the 3 subgroups with smaller vessel sizes, the adjusted risk of MACE in DES recipients was reduced by 82% in Q1 (hazard ratio [HR]: 0.18, 95% confidence interval [CI]: 0.09-0.38), 49% in Q2 (HR: 0.51, 95% CI: 0.26-0.98), and 67% in Q3 (HR: 0.33, 95% CI: 0.15-0.73). However, in the largest vessel subgroup (>3.75 mm), all clinical outcomes were not significantly different irrespective of the stent type used. CONCLUSIONS The incidence of MACE in 3.0-3.75 mm vessels was significantly reduced by the use of DES than by the use of BMS during a long-term follow-up. However, DES lost its benefit in >3.75 mm vessels.

Clinical outcomes of peripartum cardiomyopathy: a 15-year nationwide population-based study in Asia

Abstract Peripartum cardiomyopathy (PPCM) is the development of heart failure during late pregnancy to months postpartum with potential fatal outcome. However, the disease is not well-studied in Asia. We aimed to investigate the epidemiology and clinical outcomes of PPCM in Taiwan. Electronic medical records were retrieved from Taiwan National Health Insurance Research Database from 1997 to 2011. Patients with PPCM were separated into 3 groups based on the timing of diagnosis. Early: PPCM diagnosed first to ninth month of pregnancy. Traditional: PPCM diagnosed last month of pregnancy till fifth month post-delivery. Late: PPCM diagnosed sixth to twelfth month post-delivery. Primary outcomes defined as cardiac death, all-cause mortality, and major adverse cardiovascular events (MACE) within 1 year. A total of 3,506,081 deliveries during 1997 to 2011 were retrieved and 925 patients with PPCM were identified. Overall incidence of PPCM was 1:3,790 during the 15 years. Early, Traditional, and Late group each had 88, 742, and 95 patients. Cardiac death occurred in 31 patients, all-cause mortality in 72 patients, and MACE in 65 patients. Late group had 2- to 3-fold event rates in cardiac death, all-cause mortality, and MACE compared with Early and Traditional groups. Cumulative incidence showed significant differences for cardiac death (P = .0011), all-cause mortality (P = .0031), and MACE (P = .0014) among 3 groups. Multivariate Cox model showed Late group had significantly worse outcomes after adjusted for clinical variables compared with 2 other groups. Our study is the largest national cohort among Asian countries that showed timing of diagnosis of PPCM had different outcomes. Late diagnosis portended significantly increased morbidity and mortality, even after adjusted for clinical variables.

Reversal of hoarseness with recognition of Ortner syndrome in a patient with severe mitral regurgitation

Loss of voice due to vocal cord paralysis, as in Ortner syndrome, is secondary to left recurrent laryngeal nerve palsy. Cardiovascular cause should be listed as a differential diagnosis of hoarseness and is incumbent upon the diagnostic physician to be familiar with the condition. A 56-year-old male presented to our emergency department with shortness of breath due to severe mitral regurgitation. Incidental finding of aggravating hoarseness during the past six months was suspected to be related to his cardiac condition with hugely dilated left atrium. After an ear nose and throat specialist confirmed left vocal cord paralysis, a cardiac surgeon was consulted for surgical management. The operation consisted of mitral valve repair, tricuspid valve repair, left atrial reduction, and Cox maze procedure. Three days after surgery the patient had noticeable improvement in his voice, and 3 months later he had complete resolution of the hoarseness. Awareness of Ortner syndrome and a search for treatable cause of vocal cord palsy therefore is imperative before the nerve injury becomes irreversible. <Learning objective: Hoarseness in unusual clinical setting (i.e. other than in common cold), should raise suspicion and alert physician to search for primary cause of the symptoms. Ortner syndrome, due to left recurrent laryngeal nerve palsy secondary to cardiovascular disease, is an important differential diagnosis of loss of voice. Comprehensive evaluation and timely intervention allow reversal of the damage to left recurrent laryngeal nerve, whereas delay in diagnosis may lead to permanent nerve injury.>.