Marco R. Di Tullio

Prevalence and prognostic value of subclinical left ventricular systolic dysfunction by global longitudinal strain in a community-based cohort

Global longitudinal strain (GLS) assessed by speckle‐tracking echocardiography has been proposed as a parameter able to reflect early changes in left ventricular systolic function at a stage when left ventricular ejection fraction (LVEF) is still normal. This study aimed at assessing prevalence and prognostic value of left ventricular systolic dysfunction (LVSD) assessed by echocardiographic speckle‐tracking GLS in a community‐based cohort.

Aortic atherosclerosis, hypercoagulability, and stroke the APRIS (Aortic Plaque and Risk of Ischemic Stroke) study.

OBJECTIVESnOur goal was to assess the effect of hypercoagulability on the risk of stroke in patients with aortic plaques.nnnBACKGROUNDnAtherosclerotic plaques in the aortic arch are a risk factor for ischemic stroke. Their relationship with blood hypercoagulability, which might enhance their embolic potential and affect treatment and prevention, is not known.nnnMETHODSnWe performed transesophageal echocardiography in 255 patients with first acute ischemic stroke and in 209 control subjects matched by age, gender, and race/ethnicity. The association between arch plaques and hypercoagulability, and its effect on the stroke risk, was assessed with a case-control design. Stroke patients were then followed prospectively to assess recurrent stroke and death.nnnRESULTSnLarge (> or =4 mm) arch plaques were associated with increased stroke risk (adjusted odds ratio [OR]: 2.4, 95% confidence interval [CI]: 1.3 to 4.6), especially when ulcerations or superimposed thrombus were present (adjusted OR: 3.3, 95% CI: 1.4 to 8.2). Prothrombin fragment F 1.2, an indicator of thrombin generation, was associated with large plaques in stroke patients (p = 0.02), but not in control subjects. Over a mean follow-up of 55.1 +/- 37.2 months, stroke patients with large plaques and F 1.2 over the median value had a significantly higher risk of recurrent stroke and death than those with large plaques but lower F 1.2 levels (230 events per 1,000 person-years vs. 85 events per 1,000 person-years; p = 0.05).nnnCONCLUSIONSnIn patients presenting with acute ischemic stroke, large aortic plaques are associated with blood hypercoagulability, suggesting a role for coagulation activation in the stroke mechanism. Coexistence of large aortic plaques and blood hypercoagulability is associated with an increased risk of recurrent stroke and death.

Direct Measurement of Multiple Vena Contracta Areas for Assessing the Severity of Mitral Regurgitation Using 3D TEE

OBJECTIVESnThe aim of this study was to determine whether direct measurement of multiple-jet vena contracta (VC) areas by real-time 3-dimensional (3D) transesophageal echocardiography is an accurate method for measuring the severity of mitral regurgitation (MR) in patients with multiple MR jets.nnnBACKGROUNDnBecause of the conflicting requirements of Doppler and imaging physics, measuring VC using 2-dimensional (2D) echocardiography is a difficult procedure for assessing MR severity. A real-time 3D echocardiographic measurement of the VC area has been validated in a single jet of MR, but the applicability of this method for multiple jets is unknown.nnnMETHODSnTwo-dimensional and 3D transesophageal echocardiography was performed in 60 patients with multiple functional MR jets. MR severity was assessed quantitatively using the effective regurgitant orifice area derived from 3D left ventricular volume and thermodilution data (EROAstd). Manual tracings of multiple 3D VC areas in a cross-sectional plane through the VC were obtained, and the sum of the areas was compared using EROAstd. Similarly, 2D measurement of VC diameter was obtained from a 2D transesophageal echocardiographic view to optimize the largest legion size in each jet. All VC diameters were summed and compared with EROAstd.nnnRESULTSnThe correlation of the sum of the multiple 3D VC areas with EROAstd (r = 0.90, p < 0.01) was higher than that of the sum of the multiple 2D VC diameters (r = 0.56, p < 0.01), particularly with MR degrees greater than mild (r = 0.80, p < 0.01 vs. r = 0.05, p = 0.81) and in cases of 3 or more regurgitant jets (r = 0.91, p < 0.01 vs. r = 0.46, p = 0.05).nnnCONCLUSIONSnDirect measurement of multiple VC areas using 3D transesophageal echocardiography allows for assessing MR severity in patients with multiple jets, particularly for MR degrees greater than mild and in cases of more than 2 jets, for which geometric assumptions may be challenging.

Left ventricular longitudinal strain by speckle-tracking echocardiography is associated with treatment-requiring cardiac allograft rejection.

BACKGROUNDnNoninvasive detection of rejection is a major objective in the management of heart transplant recipients.nnnMETHODS AND RESULTSnTo investigate the utility of 2-dimensional speckle-tracking echocardiography (2D-STE), we retrospectively evaluated 160 sets of endomyocardial biopsies and echocardiograms from 59 asymptomatic heart transplant recipients. Conventional International Society for Heart and Lung Transplantation grade 1B or higher rejection was considered as treatment-requiring rejection (group R), whereas International Society for Heart and Lung Transplantation grade 0 or 1A was classified as group Non-R. Left ventricular global longitudinal strain (GLS), global circumferential strain, and global radial strain were assessed by 2D-STE. Twenty-five specimens were classified into group R. GLS was significantly associated with treatment-requiring rejection, whereas neither global radial strain nor global circumferential strain were. Lower GLS remained significantly associated with an increased risk of treatment-requiring rejection (odds ratio, 1.15 [95% CI, 1.01-1.30]; P=0.03) even in multivariate analysis. GLS with the absolute value of less than 14.8% showed sensitivity and specificity of 64% and 63%, respectively, for detection of treatment-requiring rejection.nnnCONCLUSIONnThe 2D-STE-derived left ventricular GLS was associated with treatment-requiring rejection. Two-dimensional STE might be useful as a noninvasive supplemental tool for monitoring heart transplant recipients for possible treatment-requiring rejection.

Hypopharyngeal Perforation Near-Miss During Transesophageal Echocardiography

Objectives/Hypothesis: The traditional blind passage of a transesophageal echocardiography probe transorally through the hypopharynx is considered safe. Yet, severe hypopharyngeal complications during transesophageal echocardiography at several institutions led the authors to investigate whether traditional probe passage results in a greater incidence of hypopharyngeal injuries when compared with probe passage under direct visualization.

Pre-operative echocardiographic features associated with persistent mitral regurgitation after left ventricular assist device implantation

BACKGROUNDnPrevious studies have shown remarkable decrease in size of the left ventricle after left ventricular assist device (LVAD) implantation due to mechanical unloading. However, a certain number of patients continue to have significant mitral regurgitation (MR) under LVAD support. We investigated pre-operative echocardiographic features associated with persistent MR after LVAD implantation.nnnMETHODSnWe retrospectively reviewed 82 consecutive patients undergoing continuous-flow LVAD implantation between 2007 and 2010. We obtained echocardiograms performed within 2 weeks before and 1 week after surgery. We investigated the pre-operative echocardiographic findings associated with significant MR post-LVAD and compared 1-year mortality after LVAD surgery between patients with and without significant MR post-LVAD.nnnRESULTSnMR was significant in 43 patients (52.4%) before LVAD surgery. Among those, 5 underwent concomitant mitral valve repair (MVr) at the time of LVAD implantation. Of the remaining 38 patients, 25 (65.8%) showed improvement of MR, whereas 13 patients (34.2%) continued to have significant MR post-LVAD. Multivariate analysis revealed that posterior displacement of the coaptation point of mitral leaflets was significantly associated with significant MR post-LVAD (hazard ratio, 1.335; 95% confidence interval, 1.035-1.721; p = 0.026) even after adjusting for the amount of pre-operative MR flow. Post-LVAD 1-year survival of patients with and without significant MR post-LVAD was not significantly different (92.3% vs 89.1%, p = 0.826).nnnCONCLUSIONSnPre-LVAD posterior displacement of mitral leaflets may be indicative of post-operative significant MR, which would help identify echocardiographic features of functional MR refractory to simple volume reduction of the ventricle.

Relation Between Long Sleep and Left Ventricular Mass (from a Multiethnic Elderly Cohort)

Short-sleep and long-sleep duration are associated with prevalent hypertension, poor cardiovascular health, and mortality. The relation of sleep hours with increased left ventricular (LV) mass, a strong correlate of elevated blood pressure (BP) values, is not established. We conducted a cross-sectional analysis among the participants of the population-based Cardiovascular Abnormalities and Brain Lesions study. LV mass was estimated by transthoracic echocardiography. Sleep duration was assessed by reported hours of sleep on a diary kept during 24-hour BP monitoring. Multivariate linear regression models were constructed to assess the relation between sleep hours and LV mass index (LV mass divided by body surface area). Analysis of sleep hour categories (short and long sleep) was performed. Among 756 participants (mean age 71 ± 9 years, 60% women, and 71% Hispanics), the mean sleep duration was 8.6 ± 1.8 hours, and LV mass index was 103 ± 26 g/m². A J-shaped relation between sleep hours squared and LV mass index was observed adjusting for demographics and cardiovascular risk factors. Categorical analysis showed an association between long-sleep duration (>11 hours) and LV mass index (β = 7.4; p = 0.013). Long sleepers had higher diurnal systolic BP (p = 0.012) and nocturnal systolic BP (p <0.001) compared with the reference group. A great part of the variance between sleep duration and LV mass was explained by 24-hour systolic BP (β = 0.45; p <0.0001). In conclusion, self-reported long-sleep duration was associated with increased LV mass. Higher systolic BP, especially nocturnal, may account for part of the observed association.

Alteration in Subendocardial and Subepicardial Myocardial Strain in Patients with Aortic Valve Stenosis: An Early Marker of Left Ventricular Dysfunction?

BACKGROUNDnIt has been suggested that myocardial systolic impairment may not be accurately detected by the evaluation of endocardial excursion alone. The aim of this study was to test the hypothesis that changes in left ventricular (LV) subendocardial and subepicardial strain are sensitive markers of severity of aortic stenosis (AS) and LV function in patients with AS.nnnMETHODSnTransthoracic echocardiography was performed in 73 consecutive patients with AS who had preserved systolic function and in 20 controls. Longitudinal strain, subendocardial radial strain, subepicardial radial strain, and transmural radial strain were measured using LV apical and short-axis images.nnnRESULTSnThe 73 patients enrolled in this study were classified according to AS severity: mild (n = 10), moderate (n = 15), or severe (n = 48). Although transmural and subepicardial radial strain showed similar values in all groups, subendocardial radial strain and longitudinal strain could differentiate mild or moderate AS from severe AS. Only the ratio of subendocardial to subepicardial radial strain (the bilayer ratio) decreased significantly as the severity of AS increased. Bilayer ratio showed weak correlations with LV ejection fraction (r = 0.37) and E/E ratio (r = -0.33) and moderate correlations with LV mass (r = -0.55) and aortic valve area (r = 0.71). Moreover, bilayer ratio was independently associated with AS severity (P = .001). In 21 patients who underwent aortic valve replacement, subendocardial radial strain and bilayer ratio increased 7 days after surgery, whereas other echocardiographic parameters of LV function showed no improvement.nnnCONCLUSIONSnBilayer ratio can reliably differentiate patients with varying degrees of AS severity and is a sensitive marker of LV function. These findings suggest that the evaluation of subendocardial and subepicardial radial strain might be a novel method for assessing LV mechanics in patients with AS.

Endothelial function in individuals with coronary artery disease with and without type 2 diabetes mellitus

The goal of this study was to determine if individuals with coronary artery disease (CAD) and type 2 diabetes mellitus (T2DM) had greater endothelial dysfunction (ED) than individuals with only CAD. Flow-mediated dilation (FMD), calculated as percentage increase in brachial artery diameter in response to postischemic blood flow, was measured after an overnight fast in 2 cohorts. The first cohort included 76 participants in the Northern Manhattan Study with CAD; 25 also had T2DM. The second cohort was composed of 27 individuals with both T2DM and CAD who were participants in a study of postprandial lipemia. Combined, we analyzed 103 patients with CAD: 52 with T2DM (T2DM+) and 51 without T2DM (T2DM-). The 52 CAD T2DM+ subjects had a mean FMD of 3.9% +/- 3.2%, whereas the 51 CAD T2DM- subjects had a greater mean FMD of 5.5% +/- 4.0% (P < .03). An investigation of various confounders known to affect FMD identified age and body mass index as the only significant covariates in a multiple regression model. Adjusting for age and body mass index, we found that FMD remained lower in T2DM+ subjects compared with T2DM- subjects (difference, -1.99%; P < .03). In patients with CAD, the concomitant presence of T2DM is independently associated with greater ED, as measured by FMD. This finding may be relevant to the greater early and late morbidity and mortality observed in patients with both CAD and T2DM.

Accurate measurement of mitral annular area by using single and biplane linear measurements: comparison of conventional methods with the three-dimensional planimetric method

AIMSnThe planimetry method using three-dimensional (3D) echocardiography is useful for providing an accurate mitral annulus area (MAA) value. However, this method is relatively unavailable. Therefore, we evaluated the accuracy of conventional methods for MAA measurement compared with that of 3D planimetry.nnnMETHODS AND RESULTSnTwo-dimensional (2D) and 3D transoesophageal echocardiography (TEE) were performed in 70 patients. The mitral annulus diameter (MAD) was measured using four standard TEE imaging planes: four-chamber (4Ch), two-chamber (2Ch), anterior-posterior (LAX), and commissure-commissure (CC). MAA was calculated using a single diameter based on that of a circle and using two diameters based on that of an ellipse. MAA measurements using the single 4Ch MAD method (r = 0.84, P < 0.001), and two anatomically orthogonal MAD method in 4Ch/2Ch (r = 0.93, P < 0.001) and LAX/CC (r = 0.97, P < 0.001) planes correlated with 3D planimetric MAA measurements. Further analysis with Bland-Altman plots revealed that the LAX/CC MAD measurement exhibited the closest limits of agreement with the 3D planimetric MAA measurement. Notably, in patients showing an elliptical annulus shape, only LAX/CC MAD, but not 4Ch or 4Ch/2Ch MAD, provided results comparable with those of 3D planimetric MAA measurements. However, in patients with a circular annulus shape, reliable MAA measurements can be achieved using either single 4Ch MAD or any biplane MAD.nnnCONCLUSIONnConventional LAX/CC MAD can be recommended for MAA measurements in a diverse patient population. This method is applicable as an alternative to the 3D planimetric method, regardless of the mitral annulus shape.