Salim Adawi

Three-Dimensional Imaging of the Left Ventricular Outflow Tract: Impact on Aortic Valve Area Estimation by the Continuity Equation

BACKGROUND Measurement of left ventricular outflow tract (LVOT) area for estimation of aortic valve area (AVA) using two-dimensional (2D) transthoracic echocardiography (TTE) and the continuity equation assumes a round LVOT. The aim of this study was to compare measurements of LVOT area and AVA using 2D and three-dimensional (3D) TTE and cardiac computed tomographic angiography (CCTA) in an attempt to improve the accuracy of AVA estimation using TTE. METHODS Fifty patients were prospectively studied, 25 with aortic stenosis and 25 without aortic stenosis (group 1). LVOT area and AVA were estimated using 2D TTE, and LVOT area and diameters were measured using 256-slice CCTA and 3D TTE. AVA was also planimetered using CCTA in midsystole. LVOT area and AVA estimated by 2D TTE were correlated with measurements by 3D TTE and CCTA. Findings from group 1 were then validated in 38 additional patients with aortic stenosis (group 2). RESULTS LVOTs were oval in 96% of the patients in group 1, with a mean eccentricity index (diameter 2/diameter 1) of 1.26 ± 0.09 by CCTA. Compared with CCTA, 2D TTE systematically underestimated LVOT area (and therefore AVA) by 17 ± 16%. The correlation between CCTA and 3D TTE LVOT area was only moderate (r = 0.63), because of inadequate 3D transthoracic echocardiographic image quality. Mean AVA was 0.92 ± 0.44 cm(2) by 2D TTE and 1.14 ± 0.68 cm(2) by CCTA (P = .0015). After correcting AVA on 2D TTE by a factor of 1.17 (accounting for LVOT area ovality), there was no difference between 2D TTE and CCTA (0.06 ± 26 cm(2), P = .20, r = 0.86). In group 2, 2D TTE underestimated LVOT area and AVA by 16 ± 11%, similar to group 1, and AVA by TTE was 0.75 ± 0.14 cm(2) compared with 0.88 ± 0.21 cm(2) by CCTA (P < .0001). When the correction factor was applied to the group 2 results, the corrected AVA by 2D TTE (×1.17) was 0.87 ± 0.17 cm(2), similar to AVA by CCTA (P = .70). CONCLUSIONS Three-dimensional imaging revealed oval LVOTs in most patients, resulting in underestimation of LVOT area and AVA on 2D TTE by 17%. This accounted for the difference in AVA between 2D TTE and CCTA. Current 3D TTE is inadequate to accurately measure LVOT area.

Accuracy and reproducibility of left ventricular outflow tract diameter measurement using transthoracic when compared with transesophageal echocardiography in systole and diastole

AIMS Accurate measurement of left ventricular outflow tract diameter (LVOTd) is essential for reliable estimation of aortic valve area (AVA) using the continuity equation. Transesophageal echocardiography (TEE) can accurately delineate the LVOT. The aim of this study was to assess the accuracy and reproducibility of LVOTd measurement using transthoracic echocardiography (TTE) with harmonic imaging when compared with TEE, in both systole and diastole. METHODS AND RESULTS We prospectively studied 50 patients [20 with aortic stenosis (AS) and 30 without AS]. LVOTd was measured offline in a blinded fashion in both systole and diastole by two experienced observers using TTE in the parasternal long axis view and TEE in the mid-oesophageal aortic view ( approximately 130 degrees ). There was strong correlation between TTE and TEE (r=0.91). LVOTd was slightly smaller by TTE when compared with TEE (2.11+/-0.21 vs. 2.16+/-0.22 cm, mean difference -0.05+/-0.09 cm, P=0.0003). Compared with TEE, 95% (2SD) of LVOTd measurements by TTE were within +0.14 and -0.24 cm. Inter- and intra-observer variability for LVOTd was 4.8+/-4.1 and 2.8+/-1.9% for TTE and 4.2+/-3.1 and 2.5+/-1.6% for TEE (P=0.4 and 0.6). In patients with AS, estimated AVA was 0.93+/-0.22 cm(2) using TTE and 0.96+/-0.24 cm(2) using TEE, P=0.08. Diastolic LVOTd by TEE was slightly smaller compared with systolic LVOTd by TEE (-0.03+/-0.07 cm, P=0.0005), and there was strong correlation between the two (r=0.95). CONCLUSION We present the data regarding accuracy and reproducibility of LVOTd measurements by TTE when compared with TEE. LVOTd measurements at end-diastole may be helpful when systolic images are suboptimal.

Right ventricular outflow tract systolic excursion: a novel echocardiographic parameter of right ventricular function

AIMS Right ventricular (RV) function has important prognostic and therapeutic implications. Assessment of RV function using echocardiography is challenging. The aim of this study was to evaluate a new parameter of RV function, right ventricular outflow tract systolic excursion (RVOT_SE). METHODS AND RESULTS RVOT_SE was measured using M-Mode echocardiography from the parasternal short-axis view at the level of the aortic valve, and was defined as the systolic excursion of the RVOT anterior wall. RVOT_SE was measured in 50 patients (age 64 ± 18 years, 28 males) with normal RV function [RV fractional area change (FAC) ≥35% and tricuspid annular plane systolic excursion (TAPSE) ≥1.6 cm] and 40 patients (age 68 ± 12 years, 35 males) with reduced RV function (RV FAC <35% and TAPSE <1.6 cm). R.V FAC was 46 ± 7% in the normal RV group and 22 ± 5% in the reduced RV group (P < 0.0001). TAPSE was 2.2 ± 0.4 cm in the normal RV group and 1.0 ± 0.2 cm in the reduced RV group (P < 0.0001). RVOT_SE was 9.6 ± 1.5 mm in the normal RV group and 1.7 ± 1.1 mm in the reduced RV group (P < 0.0001). RVOT_SE <6 mm identified patients with reduced RV function with 100% sensitivity and 100% specificity. Survival at 1 year was 63% in patients with RVOT_SE <6 mm and 84% in patients with RVOT_SE ≥6 mm, P = 0.004. CONCLUSION RVOT_SE is a novel, simple, and promising parameter for assessing RV function, and it is associated with poor survival.

Uses and Limitations of 40 Slice Multi-Detector Row Spiral Computed Tomography for Diagnosing Coronary Lesions in Unselected Patients Referred for Routine Invasive Coronary Angiography

Background and Aims: The value of multi-detector row computed tomography (MDCT) in routine cardiology practice is uncertain. We examined the applicability of MDCT imaging for the diagnosis of obstructive coronary artery disease in a routine clinical setting. Methods: MDCT scanning (40 slice) was performed in 111 unselected patients referred for invasive coronary angiography (ICA) and findings were compared to an independent quantitative assessment of the ICA on a segmental, vessel and patient basis. Results: Sensitivity and positive predictive value for segmental disease (72.2 and 70.9% respectively, overall) were higher in patients aged ≧60 years and history of disease ≧1 year, whereas specificity and negative predictive value were high in all groups. In the patient-based analysis, sensitivity and positive predictive value (84.7 and 87.8%, respectively) were higher, the latter in keeping with the high-patient prevalence of disease, but specificity and negative predictive value (61.5 and 55.2%) were low. Conclusions: Usefulness of MDCT was significantly influenced by age, duration of coronary artery disease and female gender, and on a patient-based analysis its diagnostic accuracy was not sufficient to replace ICA in a routine clinical setting.

Non-invasive management of post-partum spontaneous left main coronary artery dissection using cardiac computed tomography angiography

Avinoam Shiran*, Salim Adawi, Ronen Rubinshtein, Mordechai Bardicef, and Eli Gutterman Department of Cardiovascular Medicine, Lady Davis Carmel Medical Center, 7 Michal St, Haifa 34362, Israel; Ruth and Bruce Rappaport Faculty of Medicine, Technion—Israel Institute of Technology, Efron St, Haifa 35254, Israel; and Department of Obstetrics and Gynecology, Lady Davis Carmel Medical Center, 7 Michal St, Haifa 34362, Israel * Corresponding author. Tel: 1972 4 825 0507; Fax: 1972 4 825 0776. E-mail: av.shiran@gmail.com

Echocardiographic Brockenbrough-Braunwald-Morrow sign.

The Brockenbrough-Braunwald-Morrow sign is the paradoxical decrease in pulse pressure during the post-extrasystole beat seen in patients with hypertrophic obstructive cardiomyopathy. We present a case of intermittent left ventricular outflow tract obstruction and secondary mitral regurgitation resulting from post-extrasystolic potentiation following a premature atrial beat, demonstrating using echocardiography the mechanism behind this sign.

Spontaneous Resolution of Severe Mitral Regurgitation in a Patient with a Flail Mitral Valve

Flail mitral valve usually causes severe mitral regurgitation, which may lead to left ventricular dysfunction if left uncorrected. The authors present a case of flail posterior mitral valve leaflet and severe mitral regurgitation in which mitral valve adaptation led to enlargement of the anterior mitral valve leaflet, decrease in mitral regurgitation, and reverse left ventricular remodeling without any need for surgery.

442 Non-myxomatous flail mitral valve: prevalence, clinical and echocardiographic characteristics and 5-year outcome

Eur J Echocardiography Abstracts Supplement, December 2006 Conclusions: In DCMP the longitudinal contraction velocity Sm is the lowest when the LV dilation is extremely large and functional MR is severe. In the contrary to organic MR in DCMP the LV volume overloading does not lead to the longitudinal contraction activation. The dynamics of Sm velocity during the disease progression should be carefully monitored in organic MR to perform surgical correction in time avoiding the LV irreversible changes.