Giacomo Cavalli

Left Ventricular Myocardial Strain by Three-Dimensional Speckle-Tracking Echocardiography in Healthy Subjects: Reference Values and Analysis of Their Physiologic and Technical Determinants

BACKGROUND Despite growing interest in applying three-dimensional (3D) speckle-tracking echocardiography (STE) to measure left ventricular (LV) myocardial deformation in various diseases, normative values for 3D speckle-tracking echocardiographic parameters and the effects of demographic, hemodynamic, and technical factors on these values are unknown. METHODS In 265 healthy volunteers (age range, 18-76; 57% women), longitudinal strain (3DLε), circumferential strain (3DCε), radial strain (3DRε), and area strain (3DAε) were measured by using vendor-specific (Vsp) 3D speckle-tracking echocardiographic equipment. LV strain was also measured by using Vsp two-dimensional (2D) and vendor-independent 3D speckle-tracking echocardiographic software packages, for comparison. RESULTS Reference values (lower limit of normality) for Vsp 3D STE were -17% to -21% (-15%) for 3DLε, -17% to -20% (-14%) for 3DCε, -31% to -36% (-26%) for 3DAε, and 47% to 59% (38%) for 3DRε. Three-dimensional longitudinal strain decreased, whereas 3DCε increased, with aging (P < .003), with different trends in men and women. Men had lower 3DLε, 3DRε, 3DAε, and 2D longitudinal strain than women (P < .02). LV 3D strain parameters were also influenced by LV volumes and mass, image quality, and temporal resolution (P < .02). Reference values obtained by Vsp 2D STE were -20% to -23% (-18%) for 2D longitudinal strain, -20% to -24% (-17%) for 2D circumferential strain, and 39% to 54% (28%) for 2D radial strain (P < .001 vs Vsp 3D STE). Significantly different 3DCε and 3DRε values were obtained with vendor-independent versus Vsp 3D STE (P < .001). CONCLUSIONS In healthy subjects, reference values of LV 3D strain parameters were significantly influenced by demographic, cardiac, and technical factors. Limits of normality of LV strain by Vsp 3D STE should not be used interchangeably with Vsp 2D STE or with Vin 3D STE software.

Sex- and method-specific reference values for right ventricular strain by 2-dimensional speckle-tracking echocardiography

Background—Despite the fact that assessment of right ventricular longitudinal strain (RVLS) carries important implications for patient diagnosis, prognosis, and treatment, its implementation in clinical settings has been hampered by the limited reference values and the lack of uniformity in software, method, and definition used for measuring RVLS. Accordingly, this study was designed to establish (1) the reference values for RVLS by 2-dimensional speckle-tracking echocardiography; and (2) their relationship with demographic, hemodynamic, and cardiac factors. Methods and Results—In 276 healthy volunteers (55% women; age, 18–76 years), free wall and septum RVLS (6 segments) and free wall RVLS (3 segments) using both 6- and 3-segment regions of interest were obtained. Feasibility of 6-segment RVLS was 92%. Free wall RVLS from 3- versus 6-segment regions of interest had similar values, yet 6-segment region of interest was more feasible (86% versus 73%; P<0.001) and reproducible. Reference values (lower limits of normality) were as follows: 6-segment RVLS, −24.7±2.6% (−20.0%) for men and −26.7±3.1% (−20.3%) for women; 3-segment RVLS, −29.3±3.4% (−22.5%) for men and −31.6±4.0% (−23.3%) for women (P<0.001). Free wall RVLS was 5±2 strain units (%) larger in magnitude than 6-segment RVLS, 10±4% larger than septal RVLS, and 2±4% larger in women than in men (P<0.001). At multivariable analysis, age, sex, pulmonary systolic pressure, right atrial minimal volume, as well as right atrial and left ventricular longitudinal strain resulted as correlates of RVLS values. Conclusions—This is the largest study providing sex- and method-specific reference values for RVLS. Our data may foster the implementation of 2-dimensional speckle-tracking echocardiography–derived RV analysis in clinical practice.

Long-term outcomes following transatrial versus transventricular repair on right ventricular function in tetralogy of Fallot

Outcomes after repair of tetralogy of Fallot (TOF) are good with either a transventricular (TV) or transatrial (TA) approach. We sought to determine if there is a relationship between the TV or TA approach and right ventricular (RV) function, and the role of residual pulmonary regurgitation (PR) on the long‐term outcomes.

Hybrid minimally invasive technique with the bidirectional rotational Evolution® mechanical sheath for transvenous lead extraction: A collaboration between electrophysiologists and cardiac surgeons

We report a case of a 63‐year‐old man referred for lead extraction with the bidirectional rotational Evolution® RL mechanical sheath because of systemic infection. As it was judged a “high‐risk” procedure, we opted for a “hybrid,” minimally invasive approach consisting in a minithoracotomic access. This technique is a feasible approach, and it might be a potential safer alternative in the most challenging transvenous lead extraction procedures.

Subcutaneous implantable cardioverter defibrillator in patients awaiting cardiac transplantation or left ventricular assist device for refractory heart failure: a feasible alternative to transvenous device?: Editorial

With an increasing population of patients with end-stage heart failure (HF), orthotopic heart transplantation (OHT) remains an important selective treatment option. Moreover, despite donor pool expansion strategies, the unbalance between organ donors and patients needing OHT led to an increase in waiting-list time; and thus, the rate of left ventricular assist device (LVAD) implantation, as bridge to either transplant or destination therapy, has more than doubled over the last 10 years. In order to prevent arrhythmic death and to improve cardiac performance in those awaiting cardiac transplantation, cardiac implantable electronic devices (CIEDs), including transvenous implantable cardioverter defibrillator (T-ICD) and cardiac resynchronization therapy device, are recommended. Thus, both the population of patients with CIED who will undergo OHT and those with CIEDs/LVAD combination are destined to increase in the future years. Interestingly, a significant portion of patients with CIEDs and advanced HF, ranging from 46% to 77%, does not have a strict pacing indication, including need of resynchronization therapy, as the main aim is primary prevention of sudden cardiac death. The subcutaneous implantable cardioverter defibrillator (S-ICD) was developed as an alternative therapy to T-ICD system, as it is a fully subcutaneous system without any transvenous or epicardial leads. Thus, the S-ICD system has the potential to decrease periprocedural implantation risks, eliminate the problem of difficult venous access, reduce endovascular mechanical stress on leads, and decrease the risk of systemic device-related infection typically observed in patients with a T-ICD, even with the limit of lack of pacing capability as either antitachycardia pacing or sustained pacing for bradycardia. Therefore, S-ICD could play an important clinical role in a significant portion of patients with HF. Furthermore, OHT and LVAD patients with an ICD have some peculiar issues related to the presence of leads inside the cardiac chambers and the venous system, which we are going to address in this paper. Concerning OHT, ICD leads are usually cut when superior vena cava section is performed during surgical operation, and the portion of the leads dwelling in the recipient’s heart is removed from the organ. Then, the proximal portion of the leads is often extracted by manual traction. However, in a non-negligible percentage of patients, ranging from 13% to 42%, this procedure results in a not complete removal of the latter portion, owing to lead–tissue adhesion within the venous system. The most common site for these retained lead fragments is the central venous system (Figure 1A). It has been described elsewhere that the presence of retained ICD lead fragments after OHT would not impact long-term morbidity and mortality. However, raising data reported different potential life-threatening complications, including lead fragment infection, pulmonary embolization, venous obstruction, and electrical interferences with other CIEDs, ranging from 3.4% to 20%. Currently, there are no data in the literature focused on S-ICD patients who received OHT, with only sporadic cases reported in larger series: Pettit et al. reported a series of 206 patients with CIED at time of OHT, in which three (1%) had S-ICD, who did not presented any early or late complication related to device removal. In addition, if needed, an implanted S-ICD can be turned off, left in site at the time of OHT, and subsequently turned on again after testing sensor vectors, with no need to re-implant another device (Figure 1B). GUEST EDITORIAL

Clinical and Prognostic Implications of Methods and Partition Values Used to Assess Left Atrial Volume by Two-Dimensional Echocardiography

Background The 2015 American Society of Echocardiography/European Association of Cardiovascular Imaging recommendations for chamber quantification suggest new abnormality threshold and severity partition values for left atrial (LA) volume that are equally valid for the biplane method of disk (MOD) summation and the area‐length method (ALM). However, they have never been clinically validated. Thus, we compared the clinical and prognostic impact of LA volume assessed by MOD and ALM by using both the 2015 and 2005 abnormality thresholds. Methods In a retrospective study of 467 patients with sinus rhythm and various cardiac conditions (median age 61 years, 68% men), maximal LA volumes were measured with MOD and ALM. Patients were followed for 3.7 ± 1.1 years to record both all‐cause mortality and cardiac death. Results Applying the 2015 cutoff values, 21% of patients with dilated LA according to the 2005 recommendations were reclassified as normal. Severity of LA dilatation was reclassified in 48% (222/467) patients. ALM provided significantly larger LA volumes than MOD (41 [32; 58] mL/m2 vs 39 [30; 55] mL/m2; P = .0150), reclassifying 18% (84/467) of patients. Patients who died had larger LA volumes measured with both MOD (57 [38; 77] mL/m2 vs 37 [30; 51] mL/m2; P < .0001) and ALM (58 [40; 82] mL/m2 vs 40 [32; 54] mL/m2; P < .0001). Regardless of the method used, LA volume was a significant factor associated with mortality, with both the 2015 and 2005 cutoff values providing similar prognostic power. Conclusions The use of 2015 partition values and different methods of LA volume measurement leads to significant changes in patients’ clinical profiles. LA enlargement is an important prognostic indicator independent of cutoff values and methods used. Care should be taken to ensure consistent measurements and interpretation of two‐dimensional echocardiography LA volume during patient follow‐up. HighlightsThe 2015 recommendations proposed a higher abnormality threshold for left atrial volume.This led to reclassification of 48% of patients according to the left atrial size.The new and previous abnormality thresholds maintained similar prognostic power.The area‐length method provided larger left atrial volumes than method of disks.It reclassified 18% of patients but did not influence prognostic significance.