Matthias Aurich

Reliability of noninvasive assessment of systolic pulmonary artery pressure by Doppler echocardiography compared to right heart catheterization: analysis in a large patient population.

Background Pulmonary artery pressure (PAP) is an important marker in cardiovascular disorders, being closely associated with morbidity and mortality. Noninvasive assessment by Doppler echocardiography is recommended by current guidelines. So far, the reliability of this method has been assessed only in small studies with contradictory results. Therefore, the aim of this study was to analyze the reliability of noninvasive PAP assessment by Doppler echocardiography compared to invasive measurements in a large patient population. Methods and Results We retrospectively analyzed data from a large tertiary cardiology department over 6 years in order to compare invasively measured PAP to estimated PAP from echocardiography examinations. N=15 516 patients fulfilled inclusion criteria and n=1695 patients with timely matched examinations (within 5 days) were analyzed. In n=1221 (72%) patients, pulmonary hypertension (PH) was diagnosed invasively (postcapillary PH: n=1122 [66%]; precapillary PH: n=99 [6%]). Systolic pulmonary artery pressure (sPAP) was 45.3±15.5 mm Hg by Doppler echocardiography and 47.4±16.4 mm Hg by right heart catheterization. Pearsons correlation coefficient was r=0.87 (P<0.0001). Mean right atrial pressure (RAP) was 12.0±5.7 mm Hg by right heart catheterization and was estimated to be 12.1±6.6 mm Hg by echocardiography (r=0.82, P<0.0001). Bland–Altman analysis showed a bias of −2.0 mm Hg for sPAP (95% limits of agreement −18.1 to +14.1 mm Hg) and +1.0 mm Hg for RAP (95% limits of agreement +0.1 to +1.9 mm Hg). Noninvasive diagnosis of pulmonary hypertension with Doppler echocardiography had a good sensitivity (87%) and specificity (79%), positive and negative predictive values (91% and 70%), as well as accuracy (85%) for a sPAP cut‐off value of 36 mm Hg (AUC 0.91, P<0.001, CI 0.90 to 0.93). Conclusions In this study, Doppler echocardiography proved to be a reliable method for the assessment of sPAP, being well suited to establish the noninvasive diagnosis of pulmonary hypertension in patients with cardiac diseases.

Green tea extract as a treatment for patients with wild-type transthyretin amyloidosis: an observational study

Background Causative treatment of patients with wild-type transthyretin amyloid cardiomyopathy (wtATTR-CM) is lacking. Recent reports indicate the potential use of epigallocatechin-3-gallate (EGCG), the most abundant catechin in green tea, to inhibit amyloid fibril formation. We sought to investigate changes of cardiac function and morphology in patients with wtATTR-CM after consumption of green tea extract (GTE). Methods Twenty-five male patients (71 [64; 80] years) with wtATTR-CM were submitted to clinical examination, echocardiography, cardiac magnetic resonance imaging (cMRI) (n=14), and laboratory testing before and after daily consumption of GTE capsules containing 600 mg epigallocatechin-3-gallate for at least 12 months. Results A significant decrease of left ventricular (LV) myocardial mass by 6% (196 [100; 247] vs 180 [85; 237] g; P=0.03) by cMRI and total cholesterol by 8.4% (191 [118; 267] vs 173 [106; 287] mg/dL; P=0.006) was observed after a 1-year period of GTE consumption. LV ejection fraction by cMRI (53% [33%; 69%] vs 54% [28%; 71%]; P=0.75), LV wall thickness (17 [13; 21] vs 18 [14; 25] mm; P=0.1), and mitral annular plane systolic excursion (10 [5; 23] vs 8 [4; 13] mm; P=0.3) by echocardiography remained unchanged. Conclusion This study supports LV mass stabilization in patients with wtATTR-CM consuming GTE potentially indicating amyloid fibril reduction.

Standardized assessment of global longitudinal and circumferential strain - a modality independent software approach

Mean GLS values were -16.2±5.3% and -17.3±5.3% for echocardiography and CMR, respectively. GLS did not differ significantly between the two imaging modalities, which showed strong correlation (r=0.86), a small bias (-1.1%) and narrow 95% limits of agreement (LOA, ±5.4%). Mean GCS values were -17.9±6.3% and -24.4 ±7.8% for echocardiography and CMR, respectively. GCS was significantly underestimated by echocardiography (p<0.001). A weaker correlation (r=0.73), a higher bias (-6.5%) and wider LOA (±10.5%) were observed for GCS. GLS showed a strong correlation (r=0.92) when image quality was good, while correlation dropped to r=0.82 with poor acoustic windows in echocardiography. GCS assessment revealed only a strong correlation (r=0.87) when echocardiographic image quality was good. No significant differences for GLS between two different echocardiographic vendors could be detected. Conclusions Quantitative assessment of GLS using a standardized software algorithm allows the direct comparison of values acquired irrespective of the imaging modality. GLS may therefore serve as a reliable parameter for the assessment of global left ventricular function in clinical routine besides standard evaluation of the ejection fraction.

Prognostic significance of semiautomatic quantification of left ventricular long axis shortening in systemic light-chain amyloidosis

Abstract Aims: To assess left ventricular long axis shortening (LAS) in patients with AL amyloidosis as a potential predictor for outcome. Methods and results: We performed a de novo echocardiographic analysis of LAS in 120 patients with biopsy-proven AL amyloidosis evaluated at first presentation before specific treatment. Additionally, 47 control subjects were analyzed retrospectivly. LAS was measured using a semiautomatic tissue motion annular displacement software algorithm (TMAD). LAS was significantly better than ejection fraction (EF) (p < 0.0001) and M-mode-derived mitral annular plane systolic excursion (MAPSE) (p < 0.05) discriminating AL patients from control subjects, while being non-inferior compared to tissue Doppler-derived peak systolic mitral annular velocity. One year outcome analysis in patients with AL amyloidosis showed that LAS remained the only significant echocardiographic parameter (HR:0.76; p < 0.005) in a multivariable Cox regression model of echocardiographic values. In a comprehensive clinical model, LAS (HR:0.72, p < 0.0001), cardiac troponin-T (HR:2.86, p < 0.01) and free light chain difference (HR:1.00; p < 0.05) were independently associated with the outcome. Assessment of LAS led to a significant integrated discrimination improvement and offered incremental information compared to EF and biomarkers. The cut-off value for LAS discriminating the endpoint was 5.8%. Conclusion: LAS was an independent predictor of survival within the first year and offers incremental information in patients with AL amyloidosis evaluated prior to specific treatment.

Prognostic relevance of elevated pulmonary arterial pressure assessed non-invasively: Analysis in a large patient cohort with invasive measurements in near temporal proximity

Background The clinical relevance of non-invasively derived pulmonary arterial pressure (PAP) by Doppler echocardiography (DE) has been questioned in the past. However, transthoracic echocardiography is used as a cornerstone examination for patients with dyspnea and suspected pulmonary hypertension (PH). This study aimed to evaluate the prognostic value of non-invasive assessed PAP in a large population of patients with known or suspected cardiopulmonary disease. Methods The analyses are based on data of patients of a tertiary cardiology center that received right heart catheterization (RHC) as well as non-invasively assessed PAP by DE within five days, and includes serological and clinical parameters in a retrospective follow-up for up to eight years. Results Of 1,237 patients, clinical follow-up was possible in 1,038 patients who were included in the statistical analysis. The mean-follow up time was 1,002 days. The composite endpoint of heart transplantation (HTx) or death occurred in n = 308 patients. Elevated PAP measured non-invasively as well as invasively had significant prognostic impact (hazard ratio (HR) 2.32; 95% confidence interval (CI) 1.78–3.04; χ2 = 37.9; p<0.001 versus HR 2.84; 95%CI 2.11–3.82; χ2 = 51.9; p<0.001, respectively). By multivariate analysis, NYHA functional class, N-terminal pro-brain natriuretic peptide, cardiac troponin T, left ventricular ejection fraction, and right ventricular dysfunction remained independently predictive. Incremental prognostic information in a multimodal approach was highly relevant. Conclusions In this comprehensive study, elevated pulmonary arterial pressure measured by DE offers similar prognostic information on survival or need for HTx as right heart catheterization. Furthermore, the addition of functional capacity and serological biomarkers delivered incremental prognostic information.

Diagnosis of cardiac involvement in systemic amyloidosis by state-of-the-art echocardiography: where are we now?

ABSTRACT Introduction: Echocardiography is the first-line imaging modality used to characterize heart compromise in systemic infiltrative diseases and to evaluate response to therapy. Cardiac amyloidosis results in progressive heart failure due to restriction of ventricular filling. However, in early stages, typical findings may not be evident, even when symptoms and signs of heart failure with preserved ejection fraction are already present. Identification of early compromise is now made possible with the advent of new echocardiography techniques as two-dimensional strain imaging. Areas covered: Diagnostic and prognostic parameters that can be assessed by echocardiography are discussed, including M-mode, two-dimensional and Doppler echocardiography, as well as by new tools as tissue Doppler imaging and strain imaging. Expert opinion: Systemic amyloidosis is a rare disorder resulting from the production of misfolded proteins, primarily light-chain (AL) immunoglobulins and transthyretin (ATTR). The prognosis of affected subjects depends mainly on the presence and the degree of cardiac involvement. Early diagnosis and treatment are mandatory in order to improve survival. We present here a proposal for structured diagnosis, an algorithm based peak systolic longitudinal left ventricular strain, combined with parameters including typical myocardial texture, increased ventricular wall thickness and the presence of some degree of left ventricular diastolic dysfunction.