Nico Van de Veire

Comparison of Aortic Root Dimensions and Geometries Before and After Transcatheter Aortic Valve Implantation by 2- and 3-Dimensional Transesophageal Echocardiography and Multislice Computed Tomography

Background—3D transesophageal echocardiography (TEE) may provide more accurate aortic annular and left ventricular outflow tract (LVOT) dimensions and geometries compared with 2D TEE. We assessed agreements between 2D and 3D TEE measurements with multislice computed tomography (MSCT) and changes in annular/LVOT areas and geometries after transcatheter aortic valve implantations (TAVI). Methods and Results—Two-dimensional circular (&pgr;×r2), 3D circular, and 3D planimetered annular and LVOT areas by TEE were compared with “gold standard” MSCT planimetered areas before TAVI. Mean MSCT planimetered annular area was 4.65±0.82 cm2 before TAVI. Annular areas were underestimated by 2D TEE circular (3.89±0.74 cm2, P<0.001), 3D TEE circular (4.06±0.79 cm2, P<0.001), and 3D TEE planimetered annular areas (4.22±0.77 cm2, P<0.001). Mean MSCT planimetered LVOT area was 4.61±1.20 cm2 before TAVI. LVOT areas were underestimated by 2D TEE circular (3.41±0.89 cm2, P<0.001), 3D TEE circular (3.89±0.94 cm2, P<0.001), and 3D TEE planimetered LVOT areas (4.31±1.15 cm2, P<0.001). Three-dimensional TEE planimetered annular and LVOT areas had the best agreement with respective MSCT planimetered areas. After TAVI, MSCT planimetered (4.65±0.82 versus 4.20±0.46 cm2, P<0.001) and 3D TEE planimetered (4.22±0.77 versus 3.62±0.43 cm2, P<0.001) annular areas decreased, whereas MSCT planimetered (4.61±1.20 versus 4.84±1.17 cm2, P=0.002) and 3D TEE planimetered (4.31±1.15 versus 4.55±1.21 cm2, P<0.001) LVOT areas increased. Aortic annulus and LVOT became less elliptical after TAVI. Conclusions—Before TAVI, 2D and 3D TEE aortic annular/LVOT circular geometric assumption underestimated the respective MSCT planimetered areas. After TAVI, 3D TEE and MSCT planimetered annular areas decreased as it assumes the internal dimensions of the prosthetic valve. However, planimetered LVOT areas increased due to a more circular geometry.

Left Ventricular Resynchronization Is Mandatory for Response to Cardiac Resynchronization Therapy: Analysis in Patients With Echocardiographic Evidence of Left Ventricular Dyssynchrony at Baseline

Background— Recent studies have demonstrated that a positive response to cardiac resynchronization therapy (CRT) is related to the presence of preimplantation left ventricular (LV) dyssynchrony. The time course and the extent of LV resynchronization after CRT implantation and their relationship to response are currently unknown. Methods and Results— One hundred consecutive patients scheduled for implantation of a CRT device were prospectively included if they met the following criteria: New York Heart Association class III to IV, LV ejection fraction ≤35%, QRS duration >120 ms, and LV dyssynchrony (≥65 ms) on color-coded tissue Doppler imaging. Immediately after CRT implantation, LV dyssynchrony was reduced from 114±36 to 40±33 ms (P<0.001), which persisted at the 6-month follow-up (35±31 ms; P<0.001 versus baseline; P=0.14 versus immediately after implantation). At the 6-month follow-up, 85% of patients were classified as responders to CRT (defined as >10% reduction in LV end-systolic volume). Immediately after implantation, the responders to CRT demonstrated a significant reduction in LV dyssynchrony from 115±37 to 32±23 ms (P<0.001). The nonresponders, however, did not show a significant reduction in LV dyssynchrony (106±29 versus 79±44 ms; P=0.08). If the extent of acute LV resynchronization was <20%, response to CRT at the 6-month follow-up was never observed. Conversely, 93% of patients with LV resynchronization ≥20% responded to CRT. Conclusions— LV resynchronization after CRT is an acute phenomenon and predicts response to CRT at 6-month follow-up in patients with echocardiographic evidence of LV dyssynchrony at baseline.

Echocardiographic reference ranges for normal cardiac chamber size: results from the NORRE study.

AIMS Availability of normative reference values for cardiac chamber quantitation is a prerequisite for accurate clinical application of echocardiography. In this study, we report normal reference ranges for cardiac chambers size obtained in a large group of healthy volunteers accounting for gender and age. Echocardiographic data were acquired using state-of-the-art cardiac ultrasound equipment following chamber quantitation protocols approved by the European Association of Cardiovascular Imaging. METHODS A total of 734 (mean age: 45.8 ± 13.3 years) healthy volunteers (320 men and 414 women) were enrolled at 22 collaborating institutions of the Normal Reference Ranges for Echocardiography (NORRE) study. A comprehensive echocardiographic examination was performed on all subjects following pre-defined protocols. There were no gender differences in age or cholesterol levels. Compared with men, women had significantly smaller body surface areas, and lower blood pressure. Quality of echocardiographic data sets was good to excellent in the majority of patients. Upper and lower reference limits were higher in men than in women. The reference values varied with age. These age-related changes persisted for most parameters after normalization for the body surface area. CONCLUSION The NORRE study provides useful two-dimensional echocardiographic reference ranges for cardiac chamber quantification. These data highlight the need for body size normalization that should be performed together with age-and gender-specific assessment for the most echocardiographic parameters.

Quantitative assessment of mitral regurgitation: comparison between three-dimensional transesophageal echocardiography and magnetic resonance imaging.

Background— Quantification of mitral regurgitation severity with 2-dimensional (2D) imaging techniques remains challenging. The present study compared the accuracy of 2D transesophageal echocardiography (TEE) and 3-dimensional (3D) TEE for quantification of mitral regurgitation, using MRI as the reference method. Methods and Results— Two-dimensional and 3D TEE and cardiac MRI were performed in 30 patients with mitral regurgitation. Mitral effective regurgitant orifice area (EROA) and regurgitant volume (Rvol) were estimated with 2D and 3D TEE. With 3D TEE, EROA was calculated using planimetry of the color Doppler flow from en face views and Rvol was derived by multiplying the EROA by the velocity time integral of the regurgitant jet. Finally, using MRI, mitral Rvol was quantified by subtracting the aortic flow volume from left ventricular stroke volume. Compared with 3D TEE, 2D TEE underestimated the EROA by a mean of 0.13 cm2. In addition, 2D TEE underestimated the Rvol by 21.6% when compared with 3D TEE and by 21.3% when compared with MRI. In contrast, 3D TEE underestimated the Rvol by only 1.2% when compared with MRI. Finally, one third of the patients in grade 1 and ≥50% of the patients in grade 2 and 3, as assessed with 2D TEE, would have been upgraded to a more severe grade, based on the 3D TEE and MRI measurements. Conclusions— Quantification of mitral EROA and Rvol with 3D TEE is feasible and accurate as compared with MRI and results in less underestimation of the Rvol as compared with 2D TEE.Background—Quantification of mitral regurgitation severity with 2-dimensional (2D) imaging techniques remains challenging. The present study compared the accuracy of 2D transesophageal echocardiography (TEE) and 3-dimensional (3D) TEE for quantification of mitral regurgitation, using MRI as the reference method. Methods and Results—Two-dimensional and 3D TEE and cardiac MRI were performed in 30 patients with mitral regurgitation. Mitral effective regurgitant orifice area (EROA) and regurgitant volume (Rvol) were estimated with 2D and 3D TEE. With 3D TEE, EROA was calculated using planimetry of the color Doppler flow from en face views and Rvol was derived by multiplying the EROA by the velocity time integral of the regurgitant jet. Finally, using MRI, mitral Rvol was quantified by subtracting the aortic flow volume from left ventricular stroke volume. Compared with 3D TEE, 2D TEE underestimated the EROA by a mean of 0.13 cm2. In addition, 2D TEE underestimated the Rvol by 21.6% when compared with 3D TEE and by 21.3% when compared with MRI. In contrast, 3D TEE underestimated the Rvol by only 1.2% when compared with MRI. Finally, one third of the patients in grade 1 and ≥50% of the patients in grade 2 and 3, as assessed with 2D TEE, would have been upgraded to a more severe grade, based on the 3D TEE and MRI measurements. Conclusions—Quantification of mitral EROA and Rvol with 3D TEE is feasible and accurate as compared with MRI and results in less underestimation of the Rvol as compared with 2D TEE.

Response of the oxygen uptake efficiency slope to exercise training in patients with chronic heart failure.

The oxygen uptake efficiency slope (OUES) is a new exercise parameter that provides prognostic power in patients with CHF. Little is known about the effects of exercise training (ET) on OUES.

Technological advances in tissue Doppler imaging echocardiography

Tissue Doppler imaging is a recently introduced echocardiographic tool for measuring myocardial velocities. In this article the physical principles and different myocardial velocity imaging modalities are discussed. Examples of practical applications and clinical use of this non-invasive imaging technique are provided.

Tissue synchronisation imaging accurately measures left ventricular dyssynchrony and predicts response to cardiac resynchronisation therapy

Background: Tissue synchronisation imaging (TSI) is a new technique to assess left ventricular (LV) dyssynchrony. Objectives: The value of using TSI to automatically assess LV dyssynchrony compared with manual assessment of LV dyssynchrony from colour-coded tissue Doppler imaging (TDI), and to evaluate the value of TSI to predict response to cardiac resynchronisation therapy (CRT). Methods: 60 symptomatic patients with heart failure with depressed LV ejection fraction (LVEF) and QRS >120 ms were evaluated clinically and echocardiographically at baseline and after 6 months of CRT. LV dyssynchrony was measured manually using velocity tracings from the colour-coded TDI and automatically using TSI. LV volumes and LVEF were assessed from two-dimensional echocardiography. Clinical responders had to exhibit an improvement in New York Heart Association functional class by ⩾1 score and an improvement by ⩾25% in 6 min walking distance after 6 months. Reverse LV remodelling was defined as a reduction of ⩾15% LV end-systolic volume. Results: An excellent correlation was observed between LV dyssynchrony measured manually and automatically derived by TSI (r = 0.95, p<0.001). 34 patients showed clinical response after 6 months of CRT and 32 patients showed reverse remodelling. Baseline characteristics were comparable between responders and non-responders, except for more extensive LV dyssynchrony in the responders: 78 (26) vs 29 (29) ms (p<0.001) as assessed manually, and 79 (29) vs 28 (27) ms (p<0.001) as assessed with TSI. Using a cut-off value of 65 ms to define extensive LV dyssynchrony, TSI had a sensitivity of 81% with a specificity of 89% to predict reverse LV remodelling. Conclusion: TSI allows automatic and reliable assessment of LV dyssynchrony and predicts reverse LV remodelling after CRT.

Optimal use of echocardiography in cardiac resynchronisation therapy

Echocardiography has several roles in patients with cardiac resynchronisation therapy (CRT). First, it can optimise selection of CRT candidates by demonstration of left ventricular (LV) dyssynchrony. Second, it can be used to assess immediate response to CRT, including detection of acute LV resynchronisation. Echocardiography is also useful to evaluate long-term benefit from CRT. Finally, echocardiography is important in optimisation of pacemaker settings, including AV and VV optimisation.

Relationship between QRS duration, left ventricular volumes and prevalence of nonviability in patients with coronary artery disease and severe left ventricular dysfunction.

Patients with coronary artery disease (CAD), a QRS duration ≥120 ms and left ventricular ejection fraction (LVEF) ≤30% are potential candidates for cardiac resynchronization therapy (CRT). Our aim was to investigate the relationship between QRS duration, left ventricular volumes and prevalence of nonviable tissue in this patient population.

Percutaneous Valve-in-Valve Procedure for Severe Paravalvular Regurgitation in Aortic Bioprosthesis

Although percutaneous aortic valve replacement (PAVR) has been used to treat severe aortic stenosis for high-risk surgical patients not suitable for conventional surgery, the feasibility of using PAVR for treatment of severe paravalvular regurgitation in patients with prior aortic valve replacement