Marina Dijos

Evaluation of Global Left Ventricular Systolic Function Using Three-Dimensional Echocardiography Speckle-Tracking Strain Parameters

BACKGROUNDnThe aim of this study was to evaluate the capacity and reproducibility of three-dimensional echocardiographic (3DE) strain parameters in the assessment of global left ventricular (LV) systolic function.nnnMETHODSnA total of 128 subjects with differing LV ejection fractions were investigated using two-dimensional echocardiographic (2DE) and 3DE strains. Three-dimensional echocardiographic strain allows obtaining longitudinal, circumferential, radial, and area strains. First, values of global longitudinal strain (GLS) by 2DE and 3DE speckle-tracking analyses were compared. Thereafter, 3DE strain parameters were correlated with LV ejection fraction and indexed output. Last, the variability of 3DE versus 2DE strain measurements as well as recorded time of analysis were assessed.nnnRESULTSnAfter excluding 21 patients for insufficient image quality, four for arrhythmia, two for severe valvular disease, and one for severe dyspnea, the final population consisted of 100 patients. Comparison between 2DE and 3DE GLS revealed high correspondence (r = 0.91, y = 1.04x - 0.71) and mean error measurement of -1.3% (95% confidence interval, -5.7 to 3.2). Among strain parameters, global area strain exhibited the highest correlation with LV ejection fraction (y = -1.65 + 10.4, r = -0.92, P < .001). Intraobserver measurement variability proved acceptable: 8% for GLS (vs 6% on 2DE analysis), 7% for circumferential strain (vs 15% on 2DE analysis), 7% for radial strain (vs 33% on 2DE analysis), and 5% for global area strain. The mean error between two measurements was lower with 3DE than 2DE analysis for circumferential and radial strains but similar for GLS. The mean time of analysis was of 117 ± 16 sec for 3DE analysis, which was 25% less than for 2DE analysis (P < .001).nnnCONCLUSIONSnOf all strain parameters, new 3DE area strain correlated best with common LV systolic function parameters and is thus the most promising approach, while all 3DE strain markers exhibited good reproducibility.

Estimation of Pulmonary Pressures and Diagnosis of Pulmonary Hypertension by Doppler Echocardiography: A Retrospective Comparison of Routine Echocardiography and Invasive Hemodynamics

BACKGROUNDnTo date, Doppler echocardiography is the most widespread and well-recognized technique for the noninvasive evaluation of systolic pulmonary artery pressure (sPAP). However, recent studies have reported reservations about the relevance of Doppler echocardiography or the tools reliability in the diagnosis and follow-up of patients with pulmonary hypertension (PH). Thus, the aim of this dedicated retrospective study was to address the questions of Doppler echocardiographys relevance and accuracy for PH diagnosis in the routine activity of a conventional echocardiography department.nnnMETHODSnInstitutional databases were used to extract and analyze the records of 310 patients who underwent both hemodynamic and echocardiographic investigations within a single hospitalization period.nnnRESULTSnDespite an underestimation of absolute Doppler sPAP values compared with measurements on right heart catheterization, data analysis revealed a strong correlation (rxa0= 0.80, P < .00001, nxa0= 310). Targeting a mean pulmonary pressure on right heart catheterization of 25 mm Hg for the definition of PH, receiver operating characteristic curve analysis demonstrated a strong association between sPAP and PH diagnosis (area under the curve, 0.82; nxa0= 155). The cutoff obtained for sPAP was 38 mm Hg, and when applied on a second-test subgroup population (nxa0= 155), sensitivity, specificity, and accuracy were 88%, 83%, and 86%, respectively. When patients with examination intervals of <2 days were selected (nxa0= 115), sensitivity and specificity reached 89% and 89%, respectively. No combination of parameters produced an improvement on the initial results.nnnCONCLUSIONSnIn the real-world practice of a conventional echocardiography department, Doppler echocardiography is associated with high accuracy, sensitivity, and specificity for PH evaluation, thus confirming its major position as a primary noninvasive tool.

Systolic time intervals as simple echocardiographic parameters of left ventricular systolic performance: correlation with ejection fraction and longitudinal two-dimensional strain

AIMSnConventionally, the evaluation of left ventricular (LV) systolic function is based on ejection fraction assessment, which may be supplemented by other echocardiographic techniques, such as tissue Doppler imaging, 3D evaluation, and speckle tracking strains. However, these imaging modalities have a high technicity and are time-consuming, while being associated with reproducibility limitations. In this context, the usefulness of simpler measurements such as systolic time intervals (STI) by pulsed Doppler echocardiography must be emphasized.nnnMETHODS AND RESULTSnIn this multicentre study, left ventricular ejection fraction (LVEF), dP/dt(max), LV stroke volume, myocardial longitudinal deformation, aortic pre-ejectional period (PEP, ms), and left ventricular ejection time (LVET, ms) were prospectively investigated and compared in 134 consecutive heart failure (HF) patients and 43 control subjects. Feasibility of STI measurements was 100%. Intra-observer reproducibility was 98% for PEP, 96% for LVET, 87% for LVEF, and 93% for global longitudinal strain (GLS). By subgroup analyses, with increasingly altered LVEF or GLS, PEP significantly increased, whereas significantly LVET decreased, resulting in a significantly increased PEP/LVET ratio (P < 0.001). In the HF patients group, a correlation between LVEF and PEP/LVET was found, with r = 0.55 (y = -0.0083x + 0.75, P < 0.001). Based on receiver operating curve analyses, the area under the curve was 0.91 for PEP/LVET > 0.43, which allowed us to detect LVEF < 35% with a sensitivity of 87%, and a specificity of 84%.nnnCONCLUSIONnSTI can be easily and accurately measured in clinical practice, and may be used for detecting alterations in LV systolic function. Moreover, this method is likely to have potential applications in the management of HF patients.

Fast Track Echo of Abdominal Aortic Aneurysm Using a Real Pocket-Ultrasound Device at Bedside

Background: Ultraminiaturization of echographic systems extraordinarily provides the image “within” the clinical examination. Abdominal aorta aneurysm (AAA) diagnosis based on conventional evaluation with a dedicated operator and ultrasound machine is still controversial due to the lack of evidence of the proposed management and guidelines’ cost‐effectiveness. We hypothesized that less expensive ultraportable devices could identify AAA with the same level of accuracy as conventional approaches. Methods: A first step of this study was to validate the VSCANs image capabilities in patients referred to the vascular Doppler laboratory. Abdominal aorta measurements were performed by an experienced physician using conventional equipment followed by a second blinded physician using the ultraportable device VSCAN. Then, 204 patients hospitalized in our cardiology institute were prospectively included for a systematic screening of AAA at bedside using the VSCAN in order to determine the feasibility and impact of fast track evaluation compared to clinical examination. Results: A strong correlation was obtained between measurements of abdominal aorta diameters using the two ultrasound systems (r = 0.98, CI: 0.97–0.99, P < 0.001) with 100% of agreement for AAA diagnosis. In the second part of the study, visualization and measurement of the transverse diameter of the abdominal aorta was obtained in 199 patients, resulting in a feasibility of 97.5%. Among these patients, 18 AAAs were detected, which corresponds to a prevalence of 9%, whereas clinical evaluation did not detect any of them. Patients with AAA were more likely men (77.77% vs. 57.45%, P < 0.05) and hypertensive (88.8% vs. 56.9%, P < 0.05) as compared to those without AAA. Two patients with large AAA were quickly referred to the surgery department. Conclusion: Considering its low cost, diagnostic accuracy, and widespread availability, screening for AAA using an ultraportable ultrasound device such as VSCAN by an experienced physician is promising and should be used as an extension of routine physical examination in vascular patients. (Echocardiography 2012;29:285‐290)

Comparison of Resting and Exercise Echocardiographic Parameters as Indicators of Outcomes in Hypertrophic Cardiomyopathy

BACKGROUNDnBoth resting echocardiography and exercise echocardiography produce variables predictive of outcomes in patients with hypertrophic cardiomyopathy (HCM). The aim of the present study was to compare the respective value of resting and exercise echocardiographic parameters as indicators of clinical outcomes in patients with HCM.nnnMETHODSnResting and exercise echocardiography was performed prospectively in patients with HCM evaluated at the HCM Competence Center of Bordeaux and followed up every 6 months. A composite cardiac event was defined.nnnRESULTSnOne hundred fifteen patients (mean age, 51.9 ± 15.2 years; 66% men) were evaluated by echocardiography and followed for a mean period of 19 ± 11 months. Eighteen patients (16%) reached the composite end point, including 10 progressions to New York Heart Association functional class III or IV. On rest echocardiography, in patients with cardiac events during follow-up, left atrial volume index was significantly more increased, as were lateral E/E ratio and left ventricular outflow tract (LVOT) gradient, whereas mean global longitudinal strain (GLS) expressed in magnitude (14.0 ± 2.6% vs 17.0 ± 3.6%, P < .001) and peak velocities at the lateral annulus by Doppler tissue imaging were significantly reduced compared with patients without events. At peak exercise, patients who developed cardiac events were characterized by lower ejection fractions and greater LVOT gradients (76 ± 55 mm Hg vs 40 ± 40 mm Hg, P < .002). A Cox backward-entry selection model revealed that GLS ≤ 15% at rest and LVOT gradient ≥ 50 mm Hg at peak exercise were independently associated with an increased risk for poor outcomes in patients with HCM (hazard ratios, 3.8 [P = .017] and 3.3 [P = .028], respectively). On Kaplan-Meier survival analyses, peak exercise LVOT gradient evaluation showed additive value to predict outcomes, particularly in patients with rest GLS > 15% (log-rank P = .001) and despite a resting LVOT gradient ≥ 30 mm Hg (log-rank P = .001).nnnCONCLUSIONnThis study supports the value of resting GLS and of peak LVOT gradient, measured during exercise echocardiography, in identifying patients with HCM at increased risk for adverse events during follow-up.

Validation of the Smallest Pocket Echoscopic Device’s Diagnostic Capabilities in Heart Investigation

We hypothesized that, based on greyscale imaging and color Doppler capabilities, a new pocket ultrasound device (PUD) could accurately record cardiologic diagnostic findings. One hundred patients referred for conventional clinical indications underwent a standard echocardiography. Subsequently, a second physician blinded to the results performed an evaluation using the PUD on the same patients. Study end-points were echocardiographic window quality; left ventricular (LV) morphology; function; hypertrophy; right ventricular, atrial and vena caval morphologies; aortic and mitral valvulopathies; and pericardial structure. Using a scale of three grades, concordance in image quality proved good with a kappa coefficient (κ) of 0.71. Concordances between systems were excellent for LV function and morphology (κ = 0.91 and 0.96). Concordance for LV hypertrophy was good (κ = 0.74). Concordances for mitral regurgitation grades were 0.90, 0.95 and 1.00, respectively. In conclusion, a new PUD enabled scanning examinations, which showed good concordance of basic and qualitative diagnostic capability to standard echocardiographic instruments.

Paradoxical response to exercise in asymptomatic hypertrophic cardiomyopathy: a new description of outflow tract obstruction dynamics.

OBJECTIVESnThe purpose of this study was to analyze left ventricular obstruction in patients with hypertrophic cardiomyopathy (HCM) during exercise echocardiography.nnnBACKGROUNDnDespite the association of symptoms with left ventricular outflow tract obstruction in HCM, there exist paradoxical situations in which significant intraventricular gradients (>50 mm Hg) at rest occur in conjunction with excellent exercise tolerance.nnnMETHODSnTo examine this phenomenon, we performed exercise echocardiography and analyzed the clinical status of 107 HCM patients with and without resting obstruction.nnnRESULTSnAt rest, 69 patients had no obstruction and 38 exhibited an intraventricular gradient, 9 of whom exhibited a decrease in gradient of at least 30 mm Hg (99.4 ± 35.5 mm Hg to 30.2 ± 14.3 mm Hg, p < 0.001) during exercise (paradoxical response to exercise [PRE]). The PRE patients presented with a significantly lower New York Heart Association clinical class and higher left ventricular volumes and arterial pressure both at rest and during exercise than HCM patients in whom the gradient increased or did not change during stress echocardiography. Finally, PRE patients exhibited a trend toward a reduced rate of cardiac events.nnnCONCLUSIONSnOur study reports a subgroup of HCM patients, designated PRE based on a decreased intraventricular gradient during exercise. The reduced exertional obstruction may account for the better functional class and trend toward fewer clinical events in PRE patients.

Validation of a new bedside echoscopic heart examination resulting in an improvement in echo-lab workflow

BACKGROUNDnIn daily cardiology practice, porters are usually required to transfer inpatients who need an echocardiogram to the echocardiographic department (echo-lab).nnnAIMSnTo assess echo-lab personnel workflow and patient transfer delay by comparing the use of a new, ultraportable, echoscopic, pocket-sized device at the bedside with patient transfer to the echo-lab for conventional transthoracic echocardiography, in patients needing pericardial control after cardiac invasive procedures.nnnMETHODSnAfter validation of echoscopic capabilities for pericardial effusion, left ventricular function and mitral regurgitation grade compared with conventional echocardiography, we evaluated echo-lab personnel workflow and time to perform bedside echoscopy for pericardial control evaluation after invasive cardiac procedures. This strategy was compared with conventional evaluation at the echo-lab, in terms of personnel workflow, and patients transfer, waiting and examination times.nnnRESULTSnConcordance between echoscopy and conventional echocardiography for evaluation of pericardial effusion was good (0.97; kappa value 0.86). For left ventricular systolic function and mitral regurgitation evaluations, concordances were 0.96 (kappa value 0.90) and 0.96 (kappa value 0.86), respectively. In the second part of the study, the mean total time required in the bedside echoscopy group was 20.3±5.4 mins vs. 66.0±16.4 mins in the conventional echo-lab group (p<0.001). The echo-lab strategy needed porters in 100% of cases; 69% of patients needed a wheelchair.nnnCONCLUSIONnThe use of miniaturized echoscopic tools for pericardial control after invasive cardiac procedures was feasible and accurate, allowing improvement in echo-lab workflow and avoiding patient waiting time and transfer.

Early Detection of Left Ventricular Systolic Dysfunction Using Two-Dimensional Speckle Tracking Strain Evaluation in Healthy Subjects after Acute Alcohol Intoxication

Objectives: We evaluated the ability of two‐dimensional speckle tracking strain echocardiography to detect left ventricular (LV) systolic dysfunction as compared with LV ejection fraction (EF) in healthy subjects following acute alcohol intoxication. Methods and Results: In total, 25 healthy subjects were investigated using echocardiography 4–6 hours after the onset of alcohol intoxication at a regional festive gathering, and then compared to 23 healthy control subjects without alcohol consumption. Heart rate, blood pressure, blood alcohol level, LV volumes, EF, shortening fraction, E/A ratio, as well as global longitudinal strain (LS) were recorded. Mean blood alcohol level was 1.3 ± 0.3 g.L−1. Mean systolic blood pressure and heart rate were slightly increased in the alcohol group compared to controls (147.5 ± 21.8 mmHg vs 127.0 ± 9.9 mmHg, P = 0.003, and 79.7 ± 10.7 bpm vs 70.6 ± 7.6 bpm, P < 0.001, respectively). While there was no significant difference in terms of LVEF (62.9 ± 4.4% vs 64.8 ± 5.9%, P = 0.18) or shortening fraction (34.7 ± 5.9% vs 36.0 ± 4.3%, P = 0.54), global LS was significantly impaired (–17.8 ± 2.0% vs −21.2 ± 1.8%, P < 0.001). In addition, subjects who consumed alcohol had increased LV end‐diastolic (108.3 ± 20.1 mL vs 95.5 ± 14.6 mL, P = 0.037) and end‐systolic volumes (41.6 ± 11.4 mL vs 33.7 ± 6.9 mL, P = 0.024), along with depressed aortic time‐velocity integral (19.9 ± 3.2 mL vs 21.9 ± 2.5 mL, P = 0.034). According to multivariate linear regression analyses, blood alcohol level was the only factor significantly associated with global LS (β=−3.6 ± 1.0, P = 0.005). Conclusion: Alcohol intoxication around festive days induces acute LV contraction abnormalities, which may be detected using global LS by speckle tracking at an earlier stage and more accurately than LVEF decreases.

Efficacy and follow-up of transcatheter aortic valve implantation in patients with radiation-induced aortic stenosis

Objective To investigate transcatheter aortic valve implantation (TAVI) feasibility, effectiveness and safety in radiation-induced aortic valve stenosis cases. Methods 198 consecutive patients referred for TAVI were prospectively enrolled. They were divided into two groups: patients with a history of chest radiation therapy with suspected radiation-induced valvular disease (RXT) and others with suspected degenerative aortic valve stenosis (NRXT). Procedural, early and mid-term clinical outcomes were compared. Results Of the 198 patients enrolled in our study, 9.6% qualified for inclusion in the RXT group. A comparison of baseline characteristics revealed that patients with RXT were younger than patients with NRXT (68.3 vs 82.5u2005years; p<0.05) and exhibited a lower surgical risk score (Euroscore: 7.1% vs 21.8%; p<0.05) and a higher frequency of hostile thorax and porcelain aorta (52.6% vs 28.5%; p<0.05; 63.2% vs 10.6%; p<0.05, respectively). In both groups, the implantation success rate was high and the 30-day safety end point acceptable (RXT: 94.7% and 83.3%; NRXT: 93.9% and 75.6%, respectively). At 6u2005months, overall mortality was significantly lower in the RXT group (0% vs 18%; p=0.048). Conclusions In patients suffering from radiation-induced aortic valve stenosis and contraindicated for surgery, TAVI is a promising approach, with high feasibility, acceptable risk, low mortality and high clinical effectiveness at mid-term follow-up.