Ramdas G. Pai

Variability in Ejection Fraction Measured By Echocardiography, Gated Single-Photon Emission Computed Tomography, and Cardiac Magnetic Resonance in Patients With Coronary Artery Disease and Left Ventricular Dysfunction

Key Points Question What is the variability in left ventricular ejection fraction (LVEF) as measured by different cardiac imaging modalities? Findings In this multicenter diagnostic study of 2032 patients with coronary artery disease and LVEF of 35% or less with imaging interpreted by core laboratories, correlation of LVEF between modalities ranged from ru2009=u20090.493 (for biplane echocardiography and cardiovascular magnetic resonance) to ru2009=u20090.660 (for cardiovascular magnetic resonance and gated single-photon emission computed tomography). There was no systematic overestimation or underestimation of LVEF for any modality. Meaning There is substantial variability in LVEF assessment between modalities, which should be considered in trial design and clinical management.

Standardized echocardiography protocol for adults with congenital heart disease

Article history: Received 6 August 2018 Accepted 10 August 2018 Available online xxxx of surgery they have undergone which makes TTE imaging extremely challenging. Most of these patients would benefit from complementary imaging tools such as computed tomography (CT) scans or magnetic resonance imaging (MRI). Both these imaging tools can provide excellent images [3].MRImay bemore desirable as there is no radiation and can be used for flowquantification. Of course the downside toMRI is that itmay

Safe Transcatheter Aortic Valve Replacement in a Patient with a Highly Mobile Aortic Valve Mass

Abstract Some cardiac valve masses may have embolic potential with worrisome consequences. We describe the dilemmas of and solutions for a highly mobile papillary fibroelastoma on the aortic valve in a nonsurgical patient undergoing transcatheter aortic valve replacement. It was performed safely. The potential strategies to minimize the risk of embolization are discussed.

Deeper Into Cardiac Amyloid: Potential for Improved Outcomes

Amyloidosis refers to a group of disorders characterized by deposition of autologous fibrillary proteins into the interstitium, leading to multiple-organ dysfunction [(1)][1]. Depending upon the type, it can involve the skin, blood vessels, liver, kidney, nerves, heart, and other organs. The

Value of Cardiovascular Magnetic Resonance Imaging–Derived Baseline Left Ventricular Ejection Fraction and Volumes for Precise Risk Stratification of Patients With Ischemic Cardiomyopathy: Insights From the Surgical Treatment for Ischemic Heart Failure (STICH) Trial

Value of Cardiovascular Magnetic Resonance Imaging–Derived Baseline Left Ventricular Ejection Fraction and Volumes for Precise Risk Stratification of Patients With Ischemic Cardiomyopathy: Insights From the Surgical Treatment for Ischemic Heart Failure (STICH) Trial Ischemic cardiomyopathy accounts for approximately 50% of patients with heart failure and one-third of the patients undergoing coronary artery bypass surgery.1 Left ventricular (LV) ejection fraction (EF) and end-systolic volume index (ESVI) are predictors of mortality in these patients. Cardiovascular magnetic resonance (CMR) imaging can provide precise estimates of LV volumes and function. In the Surgical Treatment for Ischemic Heart Failure (STICH) Trial population,2 we tested the hypothesis that CMR-derived LVEF and volumes would provide improved risk stratification.

Can 3D echocardiography replace computed tomographic imaging for aortic annular sizing before transcutaneous aortic valve replacement

In this issue of the Journal, Mediratta et al.1 compare the measurement of aortic annular sizes by xray computed tomographic angiography (CTA) and 3D transesophageal echocardiography (TEE) in patients undergoing transcutaneous aortic valve replacement (TAVR). Of the 52 patients, the aortic annulus was measurable by both techniques in 47 patients. The TEE data were analyzed using a proprietary mitral valve package as well as dedicated aortic valve package. They showed that 3DTEE measurement of aortic annulus by the aortic package was comparable to CTA measurements obtained in the endsystolic phase. In 43 of 47 patients, the measurements were identical and in two patients each there was either a slight underestimation or overestimation of the annular size by 3DTEE compared to CTA. There are no outcome data in terms of prediction of paravalvular leaks to confirm, which technique is superior in this regard. Perhaps, as the discordance between techniques is rather small and that series is small, it would preclude such an analysis. Obviously, the gold standard for technique of annular sizing should be ability to implant the largest possible valve without a resultant annular rupture or paravalvular leak. Largest possible valve implant reduces the risk of patient prosthesis mismatch, which seems to be less of a problem with TAVR given a larger effective orifice area for a given valve size compared to surgical aortic valve replacement.

Unrecognized subvalvular aortic stenosis: Lessons, insights, and solutions

In this issue of the Journal, Kannappan et al.1 have investigated for the presence of discrete subaortic membrane in hypertrophic cardiomyopathy (HCM) patients. They screened 466 HCM patients in their institution and identified 15 (3%) patients with discrete subaortic membrane. Of the 15 patients, seven had left ventricular (LV) outflow tract obstruction secondary to a membrane in the absence of systolic anterior motion of the anterior mitral leaflet (SAM), while eight patients had LV outflow obstruction at two levels: at the discrete subaortic membrane and at the SAMseptal contact. The membrane was about 1.5 cm below the aortic valve. This report raises several questions and provides some answers:

Echocardiographic Laboratory Accreditation: The Pains and Pleasures.

In this issue of the journal, Gilliland et al. describe the process that they have put together for maintenance of echocardiographic laboratory certification by Intersocietal Accreditation Council (IAC) in their institution. They give enormous insights into its process, its implementation in a multicampus setup and strategies when some of the physicians may not meet the minimum volume criteria for certain types of echocardiographic studies. This paper should give practical and operational insights into both getting and maintaining echocardiographic laboratory accreditation. Obtaining and maintaining accreditation is a time-consuming and painful process with loads of paper work and need for continued documentation of various quality improvement processes and their outcomes. But, this process as well as the program that it entails has important positive consequences. It requires that all the physicians and sonographers perform to certain minimum standards and remain educated. It instills discipline in echocardiographic performance, interpretation, and reporting in all members of the echocardiographic laboratory. It mandates speedy and timely reporting which is important for rapid management decisions and shortening of hospital stay. This can improve quality of care as well as healthcare cost. Common standards will result in uniform performance and reporting of echocardiograms. Studies will become more comprehensive and reliable, and this will reduce the need for further testing. Use of appropriateness criteria and education of referring physicians to refer patients based on appropriateness criteria is likely to reduce rate of performance of inappropriate echocardiograms. Certification is also a stamp of quality and may increase referral to the certified laboratories resulting in greater proportion of high-quality echocardiograms in the community. Continuous quality improvement program ensures that echocardiographic examinations will keep getting better in a given laboratory through collaboration, incorporation of new technologies, promotion of research, and sharing of thoughts on improvement in performance, education, and workflow. Continuous quality improvement processes have been shown to reduce interpretative variability in echocardiography and improved reproducibility that can be sustained over time. This is important for monitoring various abnormalities such as left ventricular function and severity of valvular lesions as changes may have important therapeutic implications. Quality improvement processes, which should be continuous and multidisciplinary, have been shown to reduce error rates in industry and manufacturing. Errors, if they can be avoided, are unacceptable in patient care. Quality improvement processes in hospital settings have been shown to improve outcomes and reduce errors, complications, mortality, and costs. They also result in higher customer satisfaction and reinforce commitment to further changes which are beneficial to all. In summary, despite the administrative burdens, pursuit of echocardiographic laboratory certification has many positive consequences for the sonographers, physicians, hospitals, patients, and the healthcare system. Hence, it should be pursued by all echocardiographic laboratories. It should also be mandated by payers and sought after by the consumers. Address for correspondence and reprint requests: Ramdas G. Pai, M.D., F.A.C.C., F.A.S.E., F.R.C.P. (Edin), Director of Cardiac Imaging and Director of Cardiology Fellowship Program, Dignity Health – St. Bernardine Medical Center, 2101 N Waterman Ave., San Bernardino, CA 92404 USA. Fax: 909-894-4054; E-mail: ramdaspai@yahoo.com

Prevalence and Clinical Significance of an E-Reversal Wave in the Left Ventricular Outflow Tract

Diastolic waves are commonly seen in the left ventricular outflow tract on echocardiography. This work focuses on the E-reversal wave (Er) that occurs early in diastole, shortly after the mitral E wave. Factors associated with Er presence and velocity were investigated in a broad patient sample: 100 subjects with normal ejection fraction (EF >55%) and 100 subjects with reduced EF (<45%). Er presence was noted in 58% of the total cohort and correlated inversely with age. It was more common with normal EF (70% vs 45%, pxa0= 0.0005) and was associated with higher mitral E velocity (78.3 ± 23.3 vs 68.4 ± 19.0xa0cm/s; pxa0= 0.002) and septal e velocity (6.7 ± 2.5 vs 5.3 ± 2.3xa0cm/s; p <0.0001). Er velocity was higher in the normal EF group (50 ± 18 vs 34 ± 13xa0cm/s, p <0.0001) and showed moderate correlation with septal e velocity (rxa0= 0.43; p <0.0001); 56 subjects experienced major adverse cardiovascular events (MACE) over 1.7 ± 0.3xa0years of follow-up. Those with an Er had less MACE (particularly heart failure), even after adjustment for multiple clinical and echocardiographic variables (OR 0.28, 95% CI 0.11 to 0.65; pxa0= 0.003). When stratified by EF, thexa0association between Er presence and MACE was significant only in the low EF group. Thus, Er occurs more commonly in younger subjects and those with preserved EF. It is associated with less MACE although this effect appears to be limited to patients with reduced EF.