In Jeong Cho

Differential Impact of Three-Dimensional Color Doppler Echocardiography for the Quantification of Mitral Regurgitation According to the Severity and Characteristics

Background—The aim of this study is to explore the differential effect of 3-dimensional color Doppler echocardiography for the quantification of mitral regurgitation (MR). Two-dimensional color Doppler echocardiography–based MR quantification has well-documented limitations. Methods and Results—We consecutively enrolled 221 patients with MR. Adequate image quality was obtained by 2D- and 3D-color Doppler echocardiography in 211 (95.5%) patients. The quantitative differences between the MR volumes obtained by 2D- and 3D-proximal isovelocity surface area (PISA) were analyzed in various MR subgroups. In the validation cohort (n=52), MR volume obtained by 3D-PISA showed a better agreement with phase-contrast cardiac MRI than 2D-PISA (r=0.97 versus 0.84). In all 211 patients, 2D-PISA underestimated the MR volume when compared with 3D-PISA (52.4±19.6 versus 59.5±25.6 mL; P=0.005). A total of 33.3% with severe MR based on 3D-PISA were incorrectly assessed by 2D-PISA as having nonsevere MR. In the subgroup analysis, the MR severity (odds ratio, 6.96; 95% confidence interval, 3.04–15.94; P<0.001) and having an asymmetrical orifice (odds ratio, 11.48; 95% confidence interval, 3.72–35.4; P<0.001), and an eccentric jet (odds ratio, 3.82; 95% confidence interval, 1.27–11.48; P=0.017) were predictors of significant difference in MR volume (>15 mL) between 2D- and 3D-PISA methods. Conclusions—Quantification of MR by 3D-PISA method is clinically feasible and more accurate than the current 2D-PISA method. MR quantification by 2D-PISA significantly underestimated MR volume with severe, eccentric MR with an asymmetrical orifice. This article demonstrates that 3D-color Doppler echocardiography could be used as a valuable tool to confirm treatment strategy in patients with significant MR.

Late gadolinium enhancement in cardiac MRI in patients with severe aortic stenosis and preserved left ventricular systolic function is related to attenuated improvement of left ventricular geometry and filling pressure after aortic valve replacement.

Background and Objectives We investigated echocardiographic predictors: left ventricular (LV) geometric changes following aortic valve replacement (AVR) according to the late gadolinium enhancement (LGE) on cardiac magnetic resonance imaging (CMR) in patients with severe aortic stenosis (AS) and preserved LV systolic function. Subjects and Methods We analyzed 41 patients (24 males, 63.1±8.7 years) with preserved LV systolic function who were scheduled to undergo AVR for severe AS. All patients were examined with transthoracic echocardiography (TTE), CMR before and after AVR (in the hospital) and serial TTEs (at 6 and 12 months) were repeated. Results The group with LGE (LGE+) showed greater wall thickness (septum, 14.3±2.6 mm vs. 11.5±2.0 mm, p=0.001, posterior; 14.3±2.5 mm vs. 11.4±1.6 mm, p<0.001), lower tissue Doppler image (TDIS, 4.4±1.4 cm/s vs. 5.5±1.2 cm/s, p=0.021; TDI E, 3.2±0.9 cm/s vs. 4.8±1.4 cm/s, p=0.002), and greater E/e (21.8±10.3 vs. 15.4±6.3, p=0.066) than those without LGE (LGE-). Multivariate analysis show that TDI e (odds ratio=0.078, 95% confidence interval=0.007-0.888, p=0.040) was an independent determinant of LGE+. In an analysis of the 6- and 12-month follow-up compared with pre-AVR, LGE- showed decreased LV end-diastolic diameter (48.3±5.0 mm vs. 45.8±3.6 mm, p=0.027; 48.3±5.0 mm vs. 46.5±3.4 mm, p=0.019). Moreover, E/e (at 12 months) showed further improved LV filling pressure (16.0±6.6 vs. 12.3±4.3, p=0.001) compared with pre-AVR. However, LGE+ showed no significant improvement. Conclusion The absence of LGE is associated with favorable improvements in LV geometry and filling pressure. TDI E is an independent determinant of LGE in patients with severe AS and preserved LV systolic function.

Tricuspid regurgitation duration correlates with cardiovascular magnetic resonance-derived right ventricular ejection fraction and predict prognosis in patients with pulmonary arterial hypertension

AIMSnRight ventricular (RV) failure is known to be the main cause of mortality and is closely related to prognosis in patients with pulmonary arterial hypertension (PAH). A decrease in the duration of tricuspid regurgitation corrected for heart rate (TRDc) has recently been shown to be associated with advanced RV failure and poor clinical outcomes. The aim of the present study was to investigate whether TRDc correlates with RV parameters assessed using cardiovascular magnetic resonance (CMR) and has prognostic significance in patients with PAH.nnnMETHODS AND RESULTSnThirty-seven consecutive patients with PAH (28 females, age 46 ± 14 years) underwent a 6xa0min walk test, right heart catheterization, echocardiography, and CMR within a 48 h period. Tricuspid regurgitation duration corrected for heart rate, tricuspid annular plane systolic excursion (TAPSE), Tei index, and tricuspid valve lateral annular systolic velocity were measured on echocardiography, and RV end-systolic and end-diastolic volumes and ejection fraction were measured on CMR. Tricuspid regurgitation duration corrected for heart rate was positively correlated with RV ejection fraction as measured on CMR (r = 0.400, P = 0.014). On multivariate regression analysis, TRDc was also significantly correlated with RV ejection fraction even after adjusting for the eccentric index, Tei index, and TAPSE (P = 0.034). During a median follow-up period of 487 days, there were seven events (19%) including two cardiac deaths and five inpatient admissions for heart failure. The event-free survival rate was significantly higher for patients with TRDc >400 ms than those with TRDc ≤400 ms (P = 0.040).nnnCONCLUSIONnTricuspid regurgitation duration corrected for heart rate correlated with CMR-derived RV ejection fraction, and decreased TRDc was associated with cardiovascular mortality and rehospitalization in patients with PAH. Therefore, TRDc could be a useful echocardiographic surrogate marker for predicting RV dysfunction and prognosis in patients with PAH.

Automatic quantification of aortic regurgitation using 3D full volume color doppler echocardiography: a validation study with cardiac magnetic resonance imaging

Recent advances in real-time three-dimensional (3D) echocardiography provide the automated measurement of mitral inflow and aortic stroke volume without the need to assume the geometry of the heart. The aim of this study is to explore the ability of 3D full volume color Doppler echocardiography (FVCDE) to quantify aortic regurgitation (AR). Thirty-two patients with more than a moderate degree of AR were enrolled. AR volume was measured by (1) two-dimensional-CDE, using the proximal isovelocity surface area (PISA) and (2) real-time 3D-FVCDE with (3) phase-contrast cardiac magnetic resonance imaging (PC-CMR) as the reference method. Automated AR quantification using 3D-FVCDE was feasible in 30 of the 32 patients. 2D-PISA underestimated the AR volume compared to 3D-FVCDE and PC-CMR (38.6xa0±xa09.9xa0mL by 2D-PISA; 49.5xa0±xa010.2xa0mL by 3D-FVCDE; 52.3xa0±xa012.6xa0mL by PC-CMR). The AR volume assessed by 3D-FVCDE showed better correlation and agreement with PC-CMR (rxa0=xa00.93, pxa0<xa00.001, 2SD: 9.5xa0mL) than did 2D-PISA (rxa0=xa00.76, pxa0<xa00.001, 2SD: 15.7xa0mL). When used to classify AR severity, 3D-FVCDE agreed better with PC-CMR (kxa0=xa00.94) than did 2D-PISA (kxa0=xa00.53). In patients with eccentric jets, only 30xa0% were correctly graded by 2D-PISA. Conversely, almost all patients with eccentric jets (86.7xa0%) were correctly graded by 3D-FVCDE. In patients with multiple jets, only 3 out of 10 were correctly graded by 2D-PISA, while 3D-FVCDE correctly graded 9 out of 10 of these patients. Automated quantification of AR using the 3D-FVCDE method is clinically feasible and more accurate than the current 2D-based method. AR quantification by 2D-PISA significantly misclassified AR grade in patients with eccentric or multiple jets. This study demonstrates that 3D-FVCDE is a valuable tool to accurately measure AR volume regardless of AR characteristics.

Screening of Mechanical Complications of Dilated Pulmonary Artery Related to the Risk for Sudden Cardiac Death in Patients with Pulmonary Arterial Hypertension by Transthoracic Echocardiography

BACKGROUNDnIn patients with pulmonary arterial hypertension (PAH), the mechanical complications of pulmonary artery (PA) enlargement are related to sudden cardiac death (SCD). The aim of this study was to investigate the prevalence of PA enlargement, the correlation of main PA (MPA) diameter with other echocardiographic parameters,xa0and the role of transthoracic echocardiography in screening for such complications.nnnMETHODSnAmong 298 patients who were followed for PAH, patients with PA enlargement (>40xa0mm) by transthoracic echocardiography were consecutively enrolled in a prospective manner. The presence of left main and airway compression, PA dissection, or PA thrombus was determined with cardiac computed tomography.nnnRESULTSnForty-six patients (15.4%; mean age, 49xa0±xa014xa0years; 32.6% men) with dilated MPAs were enrolled. Mechanical complications were present in 16 patients (34.8%). Those with complications had more dilated MPAs compared with patients without (mean PA diameter, 55.6xa0±xa012.2 vs 46.7xa0±xa04.3xa0mm; Pxa0=xa0.012). Other echocardiographic parameters of the right heart, such as right ventricular systolic pressure, showed no differences (Pxa0>xa0.05 for all). The area under the receiver operating characteristic curve for MPA diameter was 0.750 (95% CI, 0.577-0.923; Pxa0=xa0.009), with the highest sensitivity and specificity values for the presence of complications being 85.7% and 58.6%, respectively, according to an MPA diameter of 46.5xa0mm.nnnCONCLUSIONSnMechanical complications related to sudden cardiac death in patients with PAH with dilated PAs are common. The overall performance of transthoracic echocardiography as a screening tool for predicting such complications appears reasonable. Given the burden of sudden cardiac death, measurement of PA diameter should be routinely included over the course of follow-up, especially in patients with PAH.

Echocardiographic investigation of the mechanism underlying abnormal interventricular septal motion after open heart surgery.

Background Abnormal interventricular septal motion (ASM) is frequently observed after open heart surgery (OHS). The aim of this study was to investigate the incidence and temporal change of ASM, and its underlying mechanism in patients who underwent OHS using transthoracic echocardiography (TTE). Methods In total, 165 patients [60 ± 13 years, 92 (56%) men] who underwent coronary bypass surgery or heart valve surgery were consecutively enrolled in a prospective manner. TTE was performed preoperatively, at 3--6-month postoperatively, and at the 1-year follow-up visit. Routine TTE images and strain analysis were performed using velocity vector imaging. Results ASM was documented in 121 of 165 patients (73%) immediately after surgery: 26 patients (17%) presented concomitant expiratory diastolic flow reversal of the hepatic vein, 11 (7%) had inferior vena cava plethora, and 11 (7%) had both. Only 2 patients (1%) showed clinically discernible constriction. ASM persisted 3--6 months after surgery in 38 patients (25%), but only in 23 (15%) after 1 year. There was no difference in preoperative and postoperative peak systolic strain of all segments of the left ventricle (LV) between groups with or without ASM. However, systolic radial velocity (VRad) of the mid anterior-septum and anterior wall of the LV significantly decreased in patients with ASM. Conclusion Although ASM was common (74%) immediately after OHS, it disappeared over time without causing clinically detectable constriction. Furthermore, we consider that ASM might not be caused by myocardial ischemia, but by the decreased systolic VRad of the interventricular septum after pericardium incision.

Detection of mechanical complications related to the potential risk of sudden cardiac death in patients with pulmonary arterial hypertension by computed tomography

BACKGROUNDnWe explored the value of cardiac computed tomography (CT) for the detection and prediction of mechanical complications related to the risk of sudden cardiac death (SCD) in pulmonary arterial hypertension (PAH) patients.nnnMETHODSnPAH patients (n=60, mean age 47±15, 31.7% male) with pulmonary artery (PA) enlargement (≥40mm) by echocardiography were studied with cardiac CT. Complications explored were the presence of left main coronary artery (LM) compression, airway compression, PA dissection and PA thrombosis in relation to diameters of main PA (MPA) which were measured in (1) axial plane (MPAAx) and (2) LM oblique view (MPALMobq).nnnRESULTSnMechanical complications were found in 21 patients (35.0%): LM compression in 20 patients; airway compression in 3 patients; and PA thrombosis in 4 patients. Patients with complications had more dilated MPALMobq than patients without complication (59.4±13.0mm vs. 42.4±7.0mm, p<0.001). The area under the receiver operating characteristic curve for MPALMobq was 0.889 (95% confidence interval: 0.795 to 0.983, p<0.001) with the highest discriminating sensitivity and specificity being 90.5% and 69.2%, respectively at MPALMobq of 45mm. MPAAx failed to predict the presence of mechanical complications (p>0.05).nnnCONCLUSIONnMPALMobq≥45mm was significantly associated with the presence of mechanical complications of PAH. Evaluation with CT should be considered in PAH patients with dilated MPA.

Effect of Triflusal on Primary Vascular Dysregulation Compared with Aspirin: A Double-Blind, Randomized, Crossover Trial

Purpose Primary vascular dysregulation (PVD) is a condition in which the response to cold temperature or external stimuli is abnormal. We investigated whether triflusal use results in amelioration of PVD symptoms and improvement of several related parameters compared with aspirin. Materials and Methods Eighty-eight PVD patients (54% female, 56±8 years) were randomly selected to receive either triflusal (300 mg, b.i.d.) or aspirin (150 mg, b.i.d.) for a period of 6 weeks followed by crossover. PVD was defined as both red-blood-cell standstill in video-assisted microscopic capillaroscopy during cold stimulation using carbon dioxide gas and a score of more than 7 points in a validated questionnaire. Efficacy of treatment was assessed by 1) cold intolerance symptom severity (CISS) score, 2) finger Doppler indices, and 3) indocyanine green perfusion imaging. Results The use of triflusal resulted in a greater improvement in CISS score (44.5±18.4 vs. 51.9±16.2; p<0.001) and in mean radial peak systolic velocity (69.8±17.2 vs. 66.1±16.4; p=0.011) compared to aspirin. Furthermore, significant differences were also observed in perfusion rates on indocyanine green perfusion imaging between triflusal and aspirin (45.6±25.8 vs. 51.6±26.9; p=0.020). Conclusion Triflusal was more effective and demonstrated a more consistent impact on the improvement of symptoms and blood flow in patients with PVD than aspirin.

Differential Prognostic Value of Coronary Computed Tomography Angiography in Relation to Exercise Electrocardiography in Asymptomatic Subjects

Background To explore the prognostic performance of coronary computed tomography angiography (CCTA) and exercise electrocardiography (XECG) in asymptomatic subjects. Methods We retrospectively enrolled 812 (59 ± 9 years, 60.8% male) asymptomatic subjects who underwent CCTA and XECG concurrently from 2003 through 2009. Subjects were followed-up for major adverse cardiac events (MACE) including cardiac death, nonfatal myocardial infarction, unstable angina, and revascularization after 90 days from index CCTA. Results The prevalence of occult coronary artery disease (CAD) detected by CCTA was 17.5% and 120 subjects (14.8%) had positive XECG. During a mean follow-up of 37 ± 16 months, nine subjects experienced MACE. In multivariable Cox-regression analysis, only the presence of CAD by CCTA independently predicted future MACE (p = 0.002). Moreover, CAD by CCTA improved the predictive value when added to a clinical risk factor model using the likelihood ratio test (p < 0.001). Notably, the prognostic value of CCTA persisted in the moderate-to-high-risk group as classified by the Duke treadmill score (p = 0.040), but not in the low-risk group (p = 0.991). Conclusion CCTA provides incremental prognostic benefit over and above XECG in an asymptomatic population, especially for those in a moderate-to-high-risk group as classified by the Duke treadmill score. Risk stratification using XECG may prove valuable for identifying asymptomatic subjects who can benefit from CCTA.

Prediction of hemorrhagic transformation following embolic stroke in patients with prosthetic valve endocarditis.

Background Hemorrhagic transformation (HT) of stroke is a disastrous complication in patients with infective endocarditis (IE). In patients with mechanical heart valves complicated by IE, physicians struggle with the appropriateness of anticoagulation administration given the risk of thromboembolism and HT of stroke. In this study, we aimed to define predictive parameters of HT of stroke in patients with prosthetic valve endocarditis (PVE). Methods This study was a multicenter, retrospective design. We recruited from 7 institutions a total of 111 patients diagnosed with PVE during May, 2011 to April, 2012. Results Complication of stroke was seen in 26/111 patients (23%), and HT of stroke was seen in 11/111 patients (10%). Most patients with HT (9/11, 82%) had supratherapeutic prothrombin times. However, there were no significant differences in clinical and laboratory values between PVE patients without stroke and those patients who had a stroke and with or without concurrent HT. Furthermore, echocardiographic parameters also did not show significant between-group differences. Conclusion Even though this was a multicenter study, a limited number of patients was identified and may explain the negative results seen here. However, a large number of PVE patients with stroke also developed HT. Therefore, further studies to define predictive parameters of HT should be implemented in a larger population.