Tadafumi Sugimoto

3D echocardiographic reference ranges for normal left ventricular volumes and strain: results from the EACVI NORRE study

Aim To obtain the normal ranges for 3D echocardiography (3DE) measurement of left ventricular (LV) volumes, function, and strain from a large group of healthy volunteers. Methods and results A total of 440 (mean age: 45 ± 13 years) out of the 734 healthy subjects enrolled at 22 collaborating institutions of the Normal Reference Ranges for Echocardiography (NORRE) study had good-quality 3DE data sets that have been analysed with a vendor-independent software package allowing homogeneous measurements regardless of the echocardiographic machine used to acquire the data sets. Upper limits of LV end-diastolic and end-systolic volumes were larger in men (97 and 42 mL/m2) than in women (82 and 35 mL/m2; P < 0.0001). Conversely, lower limits of LV ejection fraction were higher in women than in men (51% vs. 50%; P < 0.01). Similarly, all strain components were higher in women than in men. Lower range was -18.6% in men and -19.5% in women for 3D longitudinal strain, -27.0% and -27.6% for 3D circumferential strain, -33.2% and -34.4% for 3D tangential strain and 38.8% and 40.7% for 3D radial strain, respectively. LV volumes decreased with age in both genders (P < 0.0001), whereas LV ejection fraction increased with age only in men. Among 3DE LV strain components, the only one, which did not change with age was longitudinal strain. Conclusion The NORRE study provides applicable 3D echocardiographic reference ranges for LV function assessment. Our data highlight the importance of age- and gender-specific reference values for both LV volumes and strain.

Echocardiographic reference ranges for normal left ventricular 2D strain: results from the EACVI NORRE study

Aims To obtain the normal ranges for 2D echocardiographic (2DE) measurements of left ventricular (LV) strain from a large group of healthy volunteers accounting for age and gender. Methods and results A total of 549 (mean age: 45.6 ± 13.3 years) healthy subjects were enrolled at 22 collaborating institutions of the Normal Reference Ranges for Echocardiography (NORRE) study. 2DE data sets have been analysed with a vendor-independent software package allowing homogeneous measurements irrespective of the echocardiographic equipment used to acquire the data sets. The lowest expected values of LV strains and twist calculated as ± 1.96 standard deviations from the mean were -16.7% in men and -17.8% in women for longitudinal strain, -22.3% and -23.6% for circumferential strain, 20.6% and 21.5% for radial strain, and 2.2 degrees and 1.9 degrees for twist, respectively. In multivariable analysis, longitudinal strain decreased with age whereas the opposite occurred with circumferential and radial strain. Male gender was associated with lower strain for longitudinal, circumferential, and radial strain. Inter-vendor differences were observed for circumferential and radial strain despite the use of vendor-independent software. Importantly, no intervendor differences were noted in longitudinal strain. Conclusion The NORRE study provides contemporary, applicable 2D echocardiographic reference ranges for LV longitudinal, radial, and circumferential strain. Our data highlight the importance of age- and gender-specific reference values for LV strain.

Echocardiographic reference ranges for normal left atrial function parameters: results from the EACVI NORRE study

Aims To obtain the normal ranges for echocardiographic measurements of left atrial (LA) function from a large group of healthy volunteers accounting for age and gender. Methods and results A total of 371 (median age 45 years) healthy subjects were enrolled at 22 collaborating institutions collaborating in the Normal Reference Ranges for Echocardiography (NORRE) study of the European Association of Cardiovascular Imaging (EACVI). Left atrial data sets were analysed with a vendor-independent software (VIS) package allowing homogeneous measurements irrespective of the echocardiographic equipment used to acquire data sets. The lowest expected values of LA function were 26.1%, 48.7%, and 41.4% for left atrial strain (LAS), 2D left atrial emptying fraction (LAEF), and 3D LAEF (reservoir function); 7.7%, 24.2%, and -0.53/s for LAS-active, LAEF-active, and LA strain rate during LA contraction (SRa) (pump function) and 12.0% and 21.6% for LAS-passive and LAEF-passive (conduit function). Left atrial reservoir and conduit function were decreased with age while pump function was increased. All indices of reservoir function and all LA strains had no difference in both gender and vendor. However, inter-vendor differences were observed in LA SRa despite the use of VIS. Conclusion The NORRE study provides contemporary, applicable echocardiographic reference ranges for LA function. Our data highlight the importance of age-specific reference values for LA functions.

LEFT ATRIAL DYNAMICS DURING EXERCISE IN HEART FAILURE WITH REDUCED, MID-RANGE, AND PRESERVED EJECTION FRACTION: INSIGHTS FROM EXERCISE ECHOCARDIOGRAPHY COMBINED WITH GAS EXCHANGE ANALYSIS

The hemodynamic impact of left atrial (LA) dynamic response in heart failure (HF) on cardiopulmonary function and RV-to-PC coupling at exercise is a matter of recent interest. 120 patients with HF reduced (rEF, n=70), mid-range (mrEF, n=25) and preserved (pEF, n=25) ejection fraction underwent CPET

Association of Left Ventricular Global Longitudinal Strain With Asymptomatic Severe Aortic Stenosis: Natural Course and Prognostic Value

Importance The optimal timing to operate in patients with asymptomatic severe aortic stenosis (AS) remains controversial. Left ventricular global longitudinal strain (LV GLS) may help to identify patients who might benefit from undergoing earlier aortic valve replacement. Objective To investigate the prevalence of impaired LV GLS, the natural course of LV GLS, and its prognostic implications in patients with asymptomatic severe AS with preserved left ventricular ejection fraction (LVEF). Design, Setting, and Participants This registry-based study included the institutional registries of 3 large tertiary referral centers and 220 patients with asymptomatic severe AS and preserved LVEF (>50%) who were matched for age and sex with 220 controls without structural heart disease. The echocardiograms of patients and controls were performed between 1998 and 2017. Exposures Both clinical and echocardiographic data were assessed retrospectively. Severe AS was defined by an indexed aortic valve area less than 0.6 cm2/m2. Left ventricular global longitudinal strain was evaluated on transthoracic echocardiography using speckle tracking imaging. Main Outcomes and Measures The prevalence of impaired LV GLS, the natural course of LV GLS, and the association of impaired LV GLS with symptom onset and the need for aortic valve intervention. Results Two hundred twenty patients (mean [SD] age, 68 [13] years; 126 men [57%]) were included. Despite comparable LVEF, LV GLS was significantly impaired in patients with asymptomatic severe AS compared with age- and sex-matched controls without AS (mean [SD] LV GLS, −17.9% [2.5%] vs −19.6% [2.1%]; P < .001). After a median follow-up of 12 (interquartile range, 7-23) months, mean (SD) LV GLS significantly deteriorated (−18.0% [2.6%] to −16.3% [2.8%]; P < .001) while LVEF remained unchanged. Patients with impaired LV GLS at baseline (>−18.2%) showed a higher risk for developing symptoms (P = .02) and needing aortic valve intervention (P = .03) at follow-up compared with patients with more preserved LV GLS (⩽−18.2%). Conclusions and Relevance Subclinical myocardial dysfunction that is characterized by impaired LV GLS is often present in patients with asymptomatic severe AS with preserved LVEF. Left ventricular global longitudinal strain further deteriorates over time and impaired LV GLS at baseline is associated with an increased risk for progression to the symptomatic stage and the need for aortic valve intervention.

Management of Asymptomatic Severe Degenerative Mitral Regurgitation

ABSTRACT The decision for surgery in the management of asymptomatic severe degenerative mitral regurgitation (MR) is about doing the right thing at the right time and place. European and American guidelines have provided us with guidance on surgical indications, albeit with different levels of recommendations. However, the timing for surgery especially in asymptomatic patients not meeting Class I indications for intervention, i.e. no evidence of left ventricular dysfunction is still avidly debated. In this review, we will present the literature on the indications and timing of surgical intervention in asymptomatic severe MR, covering guidelines from both societies. We will also touch on the emerging role of other imaging techniques, biomarkers and exercise stress testing. Finally, we will present arguments for and against both management strategies, i.e. early surgery and watchful waiting. To summarize, the management of patients with asymptomatic severe degenerative MR should be a joint decision between all members of the Heart Team and tailored according to the availability of surgical expertise, patient’s surgical risk and patient’s wishes.

Exercise Testing in Mitral Regurgitation

Mitral regurgitation (MR) is the second most common valvular heart disease referred for corrective surgery. Diagnostic and management dilemmas are not uncommon when dealing with MR patients. Exercise testing plays an important role in sorting out some of these clinical challenges. In primary asymptomatic MR, exercise testing allows symptom assessment, confident link of symptoms to valve disease severity, safe deferral of surgery for the next 1-year in patients with preserved exercise capacity, insights into the mechanism of exercise-induced dyspnea and helps in individual risk stratification. Moreover, exercise testing in the form of exercise stress echocardiography is also useful in the evaluation of patients with secondary ischemic MR for risk stratification as well as for the detection of patients with moderate ischemic MR in whom mitral valve repair at the time of surgical revascularization may add benefit.

Adult echocardiographic nomograms: overview, critical review and creation of a software for automatic, fast and easy calculation of normal values

There is a crescent interest on normal adult echocardiographic values and the introduction of new deformation imaging and 3D parameters pose the issue of normative data. A multitude of nomograms has been recently published, however data are often fragmentary, difficult to find, and their strengths/limitations have been never evaluated. AIMS (I) to provide a review of current echocardiographic nomograms; (II) to generate a tool for easy and fast access to these data. A literature search was conducted accessing the National Library of Medicine using the keywords: 2D/3D echocardiography, strain, left/right ventricle, atrial, mitral/tricuspid valve, aorta, reference values/nomograms/normal values. Adding the following keywords, the results were further refined: range/intervals, myocardial velocity, strain rate and speckle tracking. Forty one published studies were included. Our study reveals that for several of 2D/3D parameters sufficient normative data exist, however, a few limitations still persist. For some basic parameters (i.e., mitral/tricuspid/pulmonary valves, great vessels) and for 3D valves data are scarce. There is a lack of studies evaluating ethnic differences. Data have been generally expressed as mean values normalised for gender and age instead of computing models incorporating different variables (age/gender/body sizes) to calculate z scores. To summarize results a software (Echocardio-Normal Values) who automatically calculate range of normality for a broad range of echocardiographic measurements according to age/gender/weight/height, has been generated. We provide an up-to-date and critical review of strengths/limitation of current adult echocardiographic nomograms. Furthermore we generated a software for automatic, easy and fast access to multiple echocardiographic normative data.

Exercise Doppler echocardiography for the diagnosis of pulmonary hypertension: renewed interest and evolving roles

Exercise-induced pulmonary hypertension (PHT) was defined historically as an increase of >30 mmHg in the mean pulmonary artery pressure (MPAP) during exercise in patients who otherwise had a normal MPAP at rest (1). This concept was adopted for almost two decades before it was dropped from the diagnostic criteria of PHT in 2008 following the 4th World Symposium on PHT due to the ambiguity in the cut-off values for abnormality (2). In recent years, however, the tide might have turned. New and improved definitions for exercise PHT have been proposed and validated in a variety of patient cohorts, generating interest and bringing exercise PHT back into the limelight (3,4). As the latest iteration of the World Symposium on PHT in Nice approaches, this paper by van Riel et al. is both timely and relevant.

Letter to the EditorExercise Echocardiography in Aortic Stenosis: A Happy End?

We read with interest the paper from Messika-Zeitoun et al. [(1)][1], which showed that neither the increase in mean pressure gradient (MPG) nor the systolic pulmonary hypertension at exercise were predictive of aortic stenosis (AS)-related events in patients with asymptomatic AS and a normal