Harry Rakowski

2011 ACCF/AHA Guideline for the Diagnosis and Treatment of Hypertrophic Cardiomyopathy A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines

Writing committee me tions to which their s ply; see Appendix ACCF/AHATask Fo Surgeons Representa tative. Heart Rhythm ography and Int Echocardiography Re ciety of America Rep resentative. kkACCF/ Task Force member d This document was app Board of Trustees and ordinating Committee gery, American Soc Cardiology, Heart Fa for Cardiovascular A geons approved the d The American Associat as follows: Gersh BJ Naidu SS, Nishimura Bernard J. Gersh, MB, ChB, DPhil, FACC, FAHA, Co-Chair* Barry J. Maron, MD, FACC, CoChair* Robert O. Bonow, MD, MACC, FAHA, Joseph A. Dearani, MD, FACC,§,k Michael A. Fifer, MD, FACC, FAHA,* Mark S. Link, MD, FACC, FHRS,* Srihari S. Naidu, MD, FACC, FSCAI,* Rick A. Nishimura, MD, FACC, FAHA, Steve R. Ommen, MD, FACC, FAHA, Harry Rakowski, MD, FACC, FASE,** Christine E. Seidman, MD, FAHA, Jeffrey A. Towbin, MD, FACC, FAHA, James E. Udelson, MD, FACC, FASNC, and Clyde W. Yancy, MD, FACC, FAHAkk

Reliability and reproducibility of two dimensional echocardiographic measurement of the stenotic mitral valve orifice area

Abstract A wide angle phased array sector scanner was used to find the optimal method, the reliability and the reproducibility of measuring the mitral valve area with two dimensional echocardiography in patients with rheumatic mitral stenosis. Initial experience with 18 patients revealed that tracing the early diastolic actual black-white interface of the perceived orifice was the most reliable method for drawing the mitral valve orifice area. Good interobserver correlation was obtained when two observers used either method to calculate the mitral valve area ( r = 0.93). Similarly good intrastudy reliability was obtained when any one observer applied one measurement method to different diastolic cycles within the same study ( r = 0.89). The phased array two dimensional echocardiogram properly differentiated patients with critical mitral stenosis from those with non-critical mitral stenosis, but the correlation between the echocardiographically and the hemodynamically derived mitral valve areas was less good than previously reported ( r = 0.83). Imaging a test object with varied known orifice sizes and excised stenotic mitral valves of known orifice size with a phased array and mechanical sector scanner failed to reveal superiority of either instrument. Further testing with a phased array instrument revealed that the perceived orifice was critically dependent on receiver gains settings for any transmitted power level. Receiver gain settings too low led to image dropout, indicating a falsely large orifice. Receiver gain settings too high led to image saturation, indicating a falsely narrowed orifice. Six additional patients with predominant mitral stenosis later underwent imaging with strict attention paid to individual receiver gain settings. Combining the data from these 6 patients with those from the initial 18 patients gave a better correlation between the echocardiographic and hemodynamic calculated mitral valve areas ( r = 0.92). Accurate noninvasive measurement of the mitral valve area with two dimensional echocardiography in patients with mitral stenosis appears to depend on use of the proper echocardiographic technique to localize the true commissural edge of the valve in early diastole, the correct instrument settings and the appropriate method for drawing the perceived orifice. The noninvasive measurement of the mitral valve orifice with two dimensional echocardiography in mitral stenosis provides clinically useful data that are reliable and reproducible if these factors are taken into account.

Clinical utility of two dimensional echocardiography in infective endocarditis

Abstract The relative value of M mode and two dimensional echocardiography for detecting masses associated with endocarditis was assessed in 58 patients with clinically suspected intracardiac infection. Original M mode and two dimensional reports were retrospectively classified as showing (1) a mass lesion, (2) an abnormality not specifically a mass, (3) no mass, or (4) a technically inadequate study. None of the 15 patients without endocarditis had an intracardiac mass recorded on echocardiography. In 36 of the 43 patients with confirmed endocarditis technically adequate M mode studies and reports were available. Five (14 percent) of the 36 M mode studies showed a mass, 12 showed a more nonspecific abnormality and 19 showed no mass. Adequate two dimensional studies were available in 42 of the 43 cases. Thirty-four (81 percent) of these studies showed a mass, seven showed a more nonspecific abnormality and one showed no mass. Two dimensional studies were specially helpful in patients with a mass on a prosthetic valve or the tricuspid valve. Clinical follow-up examination showed that 17 of the 34 patients with a mass seen on two dimensional echocardiography underwent urgent surgery for clinical indications; 4 more underwent surgery later after full medical treatment. Thirteen of the original 34 patients with a recordable mass were treated with antibiotic drugs alone. The conservative use and interpretation of the M mode echocardiograms in this study made them inferior to two dimensional studies as aids in the confident recognition of intracardiac masses associated with infective endocarditis. The presence of such masses does not in itself require surgical intervention nor does it predict the ultimate course of the patient.

Idiopathic hypertrophic subaortic stenosis viewed by wide-angle, phased-array echocardiography.

A wide-angle, phased array ultrasonic sector scanner was used to view the heart in 18 patients with idiopathic hypertrophic subaortic stenosis (IHSS). The rapid systolic anterior motion (SAM) of the mitral apparatus appeared quite separate from movement of either the left ventricular posterior wall or prominent papillary muscles. The SAM always occurred in a location judged to be the chordal end of the mitral leaflets. The SAM involved the whole mitral apparatus more extensively in patients with high outflow tract gradients at rest (> 60 mm Hg), and in all patients during Valsalva maneuver or amyl nitrite inhalation. The mitral apparatus, including the papillary muscles, was anteriorly displaced in short-axis images of these patients hearts. True end-systolic cavity obliteration was not seen at rest in any patient, since a small space persisted posteriorly between the papillary muscles in short-axis images. We believe these data support some and negate other previously proposed mechanisms for the mitral valve SAM and abnormal left ventricular dynamic geometry in patients with IHSS. Localized subaortic thick septal myocardium was seen in each case. Additionally, we noted an unusual echo pattern within the myocardium and especially in portions of the thick septum. This pattern was present along 20-100% (mean 50%) of the septal length, and 16-40% (mean 25%) of the left ventricular circumference, and in the posterobasal myocardium in two patients. We speculate that this echo pattern within the thick septal myocardium may be related to abnormal myocardial structure or myocardial fibrosis noted previously by histologic methods.

Localization of pericardial effusion with wide angle phased array echocardiography

Twenty-eight patients with proved pericardial effusions were studied in the left lateral decubitus position with an 80 degrees phased array sector scanner to determine the distribution of pericardial effusions of various sizes. Twenty-one of 28 patients were studied 2 minutes after assuming the sitting position to determine the change in the distribution of the effusions with postural change. In small volume effusions, the fluid was truly posterior at and below the atrioventricular groove. With moderate-sized effusions a more uniform distribution of the fluid was found, and with large effusions more fluid was visualized apically, posteromedially, laterally and anteriorly. Upright redistribution of the fluid was seen with moderate to large nonloculated effusions. Assumption of a uniform distribution of pericardial effusion used for M mode quantification is most valid for moderate effusions and less valid for small and large effusions. Imaging was performed in two additional patients with cardiac tamponade to assess qualitative changes in short axis ventricular volumes with respiration. The introduction of a pericardiocentesis needle was visualized. Clinical implications are discussed.

Recommendations for Training in Performance and Interpretation of Stress Echocardiography

Stress echocardiography has emerged as a clinically useful procedure in the management of patients with ischemic heart disease and other conditions. However, the accuracy of this test relies on the ability of those who carry out the technical aspects of the test and depends critically on proper interpretation of the images. Appreciation of wall motion abnormalities is generally acknowledged as one of the most difficult skills to master in echocardiography. There is consensus that this is also one of the most difficult skills to teach. Appreciating stress-induced changes in wall motion, which sometimes are subtle, requires a significant commitment to initial training in this skill and its maintenance. This document provides recommendations for physician training in stress echocardiography.

Two dimensional echocardiographic assessment of patients with bioprosthetic valves

The clinical utility of two dimensional echocardiography in assessing bioprosthetic and left ventricular function was studied in 40 consecutive patients 1 week to 60 months after valve replacement surgery. These patients were referred to obtain normal baseline studies as well as to evaluate complications:suspected endocarditis, embolic phenomena and congestive heart failure of unknown cause. Independent M mode echocardiograms were also obtained in each patient. Confirmation of ultrasonic studies was by cardiac catheterization with angiography, surgery and pathologic study in 10 patients; cardiac catheterization with angiography alone in 7 patients; surgery and pathologic study in 3 patients; autopsy in 3 patients; blood cultures to confirm or exclude endocarditis in 10 patients; and confirmation on clinical grounds in 7 patients. Technically adequate two dimensional studies were recorded in 39 of 40 subjects. Two dimensional echocardiography accurately assessed 15 of 16 patients with an abnormal bioprosthetic valve and a normal left ventricle (1 of 16 patients had a false positive two dimensional echocardiogram); 8 of 8 patients suspected to have prosthetic valve or left ventricular dysfunction but who were normal; 7 of 7 patients with a normal prosthesis and an abnormal left ventricle; the one patient with an abnormal valve and left ventricle; and 7 of 7 clinically normal patients who were referred for baseline studies. In summary, the two-dimensional echocardiogram demonstrated a 97 percent diagnostic accuracy rate which was significantly greater than the 67 percent (P less than 0.001) for M mode echocardiography in the same group of patients. It is concluded that two dimensional echocardiography has excellent diagnostic accuracy in assessing bioprosthetic and left ventricular function and is superior to M mode echocardiography in evaluating patients after such valve replacement.

Single and two-dimensional echocardiographic visualization of the effects of septal myectomy in idiopathic hypertrophic subaortic stenosis.

SUMMARY Although the postoperative hemodynamic and echocardiographic features of idiopathic hypertrophic subaortic stenosis have been studied, the expected consistent postoperative thinning of the interventricular septum has not been reported. In this study, the short-term effects of septal myectomy were evaluated in 16 patients. All patients were assessed with pre- and postoperative hemodynamic studies and M-mode echocardiograms, and six of the 16 patients had pre- and postoperative two-dimensional echocardiograms. The mean resting preoperative gradient of 74 mm Hg (range 10-190 mm Hg), which fell to a mean resting postoperative gradient of 8 mm Hg (range 0-25 mm Hg), was associated with decreased end-diastolic interventricular septal thickness at the midventricular level in 14 of 16 patients and at the subaortic level in 16 of 16 patients by M-mode echocardiography. The group also demonstrated changes in left ventricular outflow tract configuration and dimension, mitral valve systolic anterior motion, mitral E-Fo slope and left ventricular percent fractional shortening by both M-mode and two-dimensional studies. In the two patients who did not show midventricular septal thinning on M-mode echocardiography, the two-dimensional echocardiograms revealed that the area of myectomy extended only through the subaortic region and not down to the midventricular septum. Thus, we have observed consistent postmyectomy septal thinning at both the midventricular and subaortic levels by M-mode echo. By defining the geometry of the septal myectomy in vivo with two-dimensional echocardiography, we can better interpret M-mode studies and identify factors that influence echocardiographic visualization of the region of myectomy.