Pedro Marcos-Alberca

Three-dimensional-wall motion tracking: a new and faster tool for myocardial strain assessment: comparison with two-dimensional-wall motion tracking.

BACKGROUND Two-dimensional (2D) wall motion-tracking echocardiography (WMT) is a useful method to measure myocardial strain, but it is very limited because acquisition and analysis are time consuming. Three-dimensional (3D) WMT is a new method that might improve diagnostic usefulness and reduce study times. The aims of this study were to compare results on 2D and 3D WMT and to compare the times for the acquisition and analysis of regional myocardial strain between the two methods. METHODS Measurements of the radial and longitudinal strain of every left ventricular (LV) segment and the time for acquisition and analysis were obtained using 3D and 2D WMT. RESULTS Thirty patients were enrolled (mean age, 57.2 +/- 19.6 years; 60% men). Three-dimensional WMT provided complete radial and longitudinal LV strain information, similar to 2D WMT (P = NS), but it was less time consuming: the times for acquisition and analysis were 14.0 +/- 1.9 minutes with 2D WMT and 5.1 +/- 1.1 minutes with 3D WMT (P < .001). Furthermore, in the same analysis, a greater number of segments could be analyzed using 3D WMT (72.4%) compared with 2D WMT (52.0%). CONCLUSIONS Three-dimensional WMT provides a faster, more complete, and similar analysis to assess LV longitudinal and radial strain compared with 2D WMT. Thus, 3D WMT is a potential clinical bedside tool for quantifying myocardial strain.

Early myocardial deformation changes associated to isolated obesity: a study based on 3D-wall motion tracking analysis.

Obesity is considered as a strong risk factor for cardiovascular morbidity and mortality. 3D‐wall motion tracking echocardiography (3D‐WMT) provides information regarding different parameters of left ventricular (LV) myocardial deformation. Our aim was to assess the presence of early myocardial deformation abnormalities in nonselected obese children free from other cardiovascular risk factors. Thirty consecutive nonselected obese children and 42 healthy volunteer children were enrolled. None of them had any cardiovascular risk factor. Every subject underwent a 2D‐echo examination and a 3D‐WMT study. Mean age was 13.9 ± 2.56 and 13.25 ± 2.68 years in the nonobese and obese groups, respectively (59.7% and 40.3% male). Statistically significant differences were found for: interventricular septum thickness, LV posterior wall thickness, LV end‐diastolic volume, LV end‐systolic volume, left atrium volume, LV mass, and lateral annulus peak velocity. Regarding the results obtained by 3D‐WMT assessment, all the evaluated parameters were statistically significantly different between the two groups. When the influence of obesity on the different echocardiographic variables was evaluated by means of multivariate logistic regression analysis, the strongest relationship with obesity was found for LV average circumferential strain (β‐coefficient: 0.74; r2: 0.55; P: 0.003). Thus, obesity cardiomyopathy is associated not only with structural cardiac changes, but also with myocardial deformation changes. Furthermore, this association occurs as early as in the childhood and it is independent from any other cardiovascular risk factor. The most related parameter to obesity is LV circumferential strain.

Direct Measurement of Proximal Isovelocity Surface Area by Single-Beat Three-Dimensional Color Doppler Echocardiography in Mitral Regurgitation: A Validation Study

BACKGROUND The two-dimensional (2D) proximal isovelocity surface area (PISA) method has some technical limitations, mainly the geometric assumptions of PISA shape required to calculate effective regurgitant orifice area (EROA). Recently developed single-beat, real-time three-dimensional (3D) color Doppler imaging allows direct measurement of PISA without geometric assumptions. The aim of this study was to validate this novel method in patients with chronic mitral regurgitation (MR). METHODS Thirty-three patients were included, 25 (75.7%) with degenerative MR and eight (24.2%) with functional MR. EROA and regurgitant volume were assessed using transthoracic 2D and 3D PISA methods. The quantitative Doppler method and 3D transesophageal echocardiographic planimetry of EROA were used as reference methods. RESULTS Both EROA and regurgitant volume assessed using the 3D PISA method had better correlations with the reference methods than conventional 2D PISA. A consistent significant underestimation of EROA and regurgitant volume using 2D PISA was observed, particularly in the assessment of eccentric jets. On the basis of 3D transesophageal echocardiographic planimetry of EROA, 14 patients had severe MR (EROA ≥ 0.4 cm(2)). Of these 14 patients, 42.8% (6 of 14) were underestimated as having nonsevere MR (EROA ≤ 0.4 cm(2)) by the 2D PISA method. In contrast, the 3D PISA method had 92.9% (13 of 14) agreement with 3D transesophageal planimetry in classifying severe MR. Good intraobserver and interobserver agreement for 3D PISA measurements was observed, with intraclass correlation coefficients of 0.96 and 0.92, respectively. CONCLUSIONS Direct measurement of PISA without geometric assumptions using single-beat, real-time 3D color Doppler echocardiography is feasible in the clinical setting. MR quantification using this methodology is more accurate than the conventional 2D PISA method.

3D color-Doppler echocardiography and chronic aortic regurgitation: A novel approach for severity assessment

BACKGROUND 3D echocardiography provides a complete evaluation of the aortic valve and adjacent structures and it improves the assessment of this cardiac region. Three-dimensional color-Doppler echocardiography (3DCDE) evaluation might improve the measurements of the functional regurgitant orifice in patients with Chronic Aortic Regurgitation (CAR). OBJECTIVES Our aim was to compare the accuracy of current echo-Doppler methods and 3DCDE for the assessment of CAR severity. The reference method used in this work was the CAR severity determined by means of cardiac magnetic resonance (CMR) METHODS: Thirty-two consecutive patients with an established diagnosis of CAR recruited in our institution comprised our study group. CAR severity was determined by conventional Echo-Doppler methods and by 3DCDE and their results were compared with those obtained by means of CMR. RESULTS Mean age was 63.0 ± 13.5 years. Twenty-two patients (68.8%) were men. Compared with the traditional echo-Doppler methods, 3DCDE evaluation had the best linear association with CMR results (3D vena contracta cross sectional area method: r = 0.88; r square = 0.77; p < 0.001. 3D vena contracta cross sectional area/left ventricular outflow tract cross sectional area method: r = 0.87; r square = 0.75; p < 0.001). The ROC analysis showed an excellent area under curve for detection of severe CAR (3D vena contracta cross sectional area method = 0.97; 3D vena contracta cross sectional area/left ventricular outflow tract cross sectional area method = 0.98). Inter- and intra-observer variability for the 3DCDE evaluation was good (ICC = 0.89 and ICC = 0.91 for inter and intra observer variability respectively). CONCLUSIONS 3DCDE is an accurate and highly reproducible diagnostic tool for estimating CAR severity. Compared with the traditional echo-Doppler methods, 3DCDE has the best agreement with the CMR determined CAR severity. Thus, 3DCDE is a diagnostic method that may improve the therapeutic management of patients with CAR.

Proximal Isovelocity Surface Area by Single-Beat Three-Dimensional Color Doppler Echocardiography Applied for Tricuspid Regurgitation Quantification

BACKGROUND The two-dimensional (2D) proximal isovelocity surface area (PISA) method has known technical limitations, mainly the geometric assumptions of PISA shape required to calculate effective regurgitant orifice area (EROA). Recently developed single-beat real-time three-dimensional (3D) color Doppler imaging allows the direct measurement of PISA without geometric assumptions and has already been validated for mitral regurgitation assessment. The aim of this study was to apply this novel method in patients with chronic tricuspid regurgitation (TR). METHODS Ninety patients with chronic TR were enrolled. EROA and regurgitant volume (Rvol) were assessed using transthoracic 2D and 3D PISA methods. Quantitative Doppler and 3D transthoracic planimetry of EROA were used as reference methods. RESULTS Both EROA and Rvol assessed using the 3D PISA method had better correlations with the reference methods than using conventional 2D PISA, particularly in the assessment of eccentric jets. On the basis of 3D planimetry-derived EROA, 35 patients had severe TR (EROA ≥ 0.4 cm(2)). Among these 35 patients, 25.7% (n = 9) were underestimated as having nonsevere TR (EROA ≤ 0.4 cm(2)) using the 2D PISA method. In contrast, the 3D PISA method had 94.3% agreement (33 of 35) with 3D planimetry in classifying severe TR. Good intraobserver and interobserver agreement for 3D PISA measurements was observed, with intraclass correlation coefficients of 0.92 and 0.88 respectively. CONCLUSIONS TR quantification using PISA by single-beat real-time 3D color Doppler echocardiography is feasible in the clinical setting and more accurate than the conventional 2D PISA method.

Myocardial Strain Characterization in Different Left Ventricular Adaptative Responses to High Blood Pressure: A Study Based on 3D-Wall Motion Tracking Analysis

Background: High blood pressure increases left ventricular (LV) after‐load. Furthermore, LV response to that high blood pressure varies among different subjects. Nevertheless, myocardial deformation behavior in these different adaptative responses has not been analyzed until now. Methods: Prospective study in which 66 consecutive hypertensive patients were enrolled in between May and August 2009. Every patient underwent a standard echocardiographic study and a three‐dimensional‐wall motion tracking (3D‐WMT) study. The patients were classified according to parameters derived from echocardiography in four different groups: normal geometry, concentric remodelling, concentric hypertrophy, and eccentric hypertrophy. Results: Mean age was 68 years (57–74.25; 51.5% male). Comparing the four groups, significant differences were found for the five 3D‐WMT‐derived parameters. When patients were compared with hypertensive patients with normal geometry, our finding show that: (a) LV average torsion is the only impaired parameter that is found in the LV concentric remodelling group (P < 0.05 vs. group 1); (b) there is a trend for an increase (P = 0.055) in LV average radial strain in the group with concentric hypertrophy and this increase is accompanied by a significant decrease in the remaining studied parameters (P < 0.05); and (c) in the LV eccentric hypertrophy group, there is a significant impairment in all the studied parameters (P < 0.05). Conclusions: LV adaptative response to hypertension is accompanied by a modification or even impairment, in LV myocardial deformation evaluated by 3D‐WMT. This assessment might be useful to detect early and subtle deformation impairments in hypertensive patients and it could help optimize their clinical management. (Echocardiography 2010;27:1238‐1246)

Quantification of left atrial volumes using three-dimensional wall motion tracking echocardiographic technology: comparison with cardiac magnetic resonance

BACKGROUND Left atrium (LA) size assessment is clinically relevant, but the accuracy of two-dimensional echocardiographic (2D-echo) methods is limited. Three-dimensional (3D) echocardiography is an excellent alternative but is far from being used in daily clinical practice. Three-dimensional-wall motion tracking (3D-WMT) allows us to obtain volumes in a very simple and rapid manner. The aims of this study were to evaluate the accuracy of 3D-WMT technology to assess LA volume using cardiac magnetic resonance (CMR) as a reference method, to evaluate its reproducibility, and to determine its added clinical value to classify the LA enlargement severity. METHODS AND RESULTS Seventy consecutive patients referred for a CMR study were prospectively enrolled. They underwent LA volume assessment by means of 2D-echo, 3D-WMT, and CMR. Inter-methods agreement was assessed. The mean age was 56 ± 18 years and 42 patients (60%) were males. Average maximal LA volume obtained by 2D-echo, 3D-WMT, and CMR were 63.33 ± 26.82, 79.80 ± 29.0, and 79.80 ± 28.99 mL, respectively. Univariate linear regression analysis showed a good correlation between 3D-WMT and CMR (r = 0.83; P < 0.001). The agreement analysis showed a similar result (ICC = 0.83; 95% CI = 0.74-0.89; P < 0.001). Furthermore, the LA enlargement degree was better evaluated with 3D-WMT than with 2D-echo. CONCLUSION This study validates LA volume measurements obtained using the new and fast 3D-WMT technology, compared with CMR. This method is fast, accurate, and reproducible, and it allows a better classification of left LA enlargement severity compared with 2D-echo.

Usefulness of echocardiographic criteria for transcatheter aortic valve implantation without balloon predilation: a single-center experience.

BACKGROUND Transcatheter aortic valve implantation (TAVI) is an alternative therapy for high-risk patients with symptomatic aortic stenosis. TAVI without balloon aortic predilation (BPD) has been found to be as feasible and safe as the standard approach with predilation. The aim of this study was to show the usefulness of transesophageal echocardiographic (TEE) criteria during patient selection for TAVI without BPD and compare the results with those from a control group. METHODS Two hundred forty-nine consecutive patients with severe symptomatic aortic stenosis underwent echocardiographic evaluation before TAVI. Two-dimensional and three-dimensional TEE imaging was used to evaluate the aortic annulus and root, leaflet mobility and degree of calcification, orifice characteristics, valve area, and aortic regurgitation. After TEE data were reviewed, patients were considered to be favorable candidates, or not, for TAVI without BPD on the basis of specific echocardiographic criteria. RESULTS The mean age was 82 ± 5 years. Seventy-nine patients underwent TAVI without BPD, and 170 patients underwent TAVI with BPD. The mean aortic valve area was 0.61 ± 0.16 cm(2), and the mean aortic annular diameter was 2.2 ± 0.25 cm. In the group without BPD, Edwards SAPIEN XT valves were implanted in 64.6% (n = 51) and Medtronic CoreValve prostheses in 35.4% (n = 28). In this group, residual paravalvular aortic regurgitation immediately after valve deployment was seen in 53.2% of patients, without differences from those who underwent TAVI with BPD. Permanent pacemaker implantation was less frequent in the group of patients without BPD (6.3% vs 14.1%, P = .030). Procedure-related mortality was significantly lower in patients without BPD (2.5% vs 11.8%, P = .018). CONCLUSIONS Thorough TEE assessment of aortic valve features permits the selection of patients with ideal conditions for TAVI without BPD, regardless of the type of prosthesis. Using the echocardiographic criteria described here, it is possible to achieve a good rate of procedural success with a low complication rate in patients undergoing TAVI without BPD.

Proximal flow convergence method by three-dimensional color Doppler echocardiography for mitral valve area assessment in rheumatic mitral stenosis.

BACKGROUND The two-dimensional (2D) proximal isovelocity surface area (PISA) method has important technical limitations for mitral valve orifice area (MVA) assessment in mitral stenosis (MS), mainly the geometric assumptions of PISA shape and the requirement of an angle correction factor. Single-beat real-time three-dimensional (3D) color Doppler imaging allows the direct measurement of PISA without geometric assumptions or the requirement of an angle correction factor. The aim of this study was to validate this method in patients with rheumatic MS. METHODS Sixty-three consecutive patients with rheumatic MS were included. MVA was assessed using the transthoracic 2D and 3D PISA methods. Planimetry of MVA (2D and 3D) and the pressure half-time method were used as reference methods. RESULTS The 3D PISA method had better correlations with the reference methods (with 2D planimetry, r = 0.85, P < .001; with 3D planimetry, r = 0.89, P < .001; and with pressure half-time, r = 0.85, P < .001) than the conventional 2D PISA method (with 2D planimetry, r = 0.63, P < .001; with 3D planimetry, r = 0.66, P < .001; and with pressure half-time, r = 0.68, P < .001). In addition, a consistent significant underestimation of MVA using the conventional 2D PISA method was observed. A high percentage (30%) of patients with nonsevere MS by 3D planimetry were misclassified by the 2D PISA method as having severe MS (effective regurgitant orifice area < 1 cm(2)). In contrast, the 3D PISA method had 94% agreement with 3D planimetry. Good intra- and interobserver agreement for 3D PISA measurements were observed, with intraclass correlation coefficients of 0.95 and 0.90, respectively. CONCLUSIONS MVA assessment using PISA by single-beat real-time 3D color Doppler echocardiography is feasible in the clinical setting and more accurate than the conventional 2D PISA method.

Estudio de la deformación miocárdica: predictor de disfunción ventricular a medio plazo tras cirugía en pacientes con insuficiencia mitral crónica

Introduccion y objetivos. El desarrollo de disfuncion ventricular izquierda tras la sustitucion valvular mitral es un problema frecuente en pacientes con insuficiencia mitral grave cronica. El analisis de la deformacion miocardica permite estimar con precision la contractilidad miocardica. Nuestro objetivo fue comparar el valor predictivo de strain (S) y strain rate (SR) preoperatorios obtenidos por speckle-tracking y Doppler tisular (DTI) para predecir la disminucion de la fraccion de eyeccion del ventriculo izquierdo (FEVI) a medio plazo tras la cirugia. Metodos. Treinta y ocho pacientes consecutivos con insuficiencia mitral grave cronica programados para sustitucion valvular mitral fueron incluidos prospectivamente. Se analizo el S y el SR longitudinal del septo interventricular en el periodo preoperatorio mediante speckle-tracking y DTI. La FEVI preoperatoria y postoperatoria se obtuvo por ecocardiografia tridimensional. Los estudios ecocardiograficos se realizaron dentro de las 48 h previas a la cirugia y 6 meses despues de la cirugia. Resultados. La media de edad de los pacientes era 59,9 ± 11,3 anos; 10 pacientes (29,4%) eran varones. Tanto el speckle-tracking como el DTI resultaron predictores de disminucion de la FEVI > 10% a 6 meses. Sin embargo, el valor predictivo del speckle-tracking fue superior al del DTI. El S longitudinal del septo interventricular basal mediante speckle-tracking fue el parametro con mayor poder predictivo, con un area bajo la curva de 0,85 y un punto de corte optimo de -0,11. Conclusiones. El speckle-tracking permite predecir la disminucion de la FEVI a medio plazo tras la sustitucion valvular mitral. Ademas, el speckle-tracking es mas preciso que el DTI para este fin.