Yoko Fukuoka

Mechanisms of Acute Mitral Regurgitation in Patients With Takotsubo Cardiomyopathy An Echocardiographic Study

Background—Recent studies have suggested acute mitral regurgitation (MR) as a potentially serious complication of takotsubo cardiomyopathy (TTC); however, the mechanism of acute MR in TTC remains unclear. The aim of this study was to elucidate the mechanisms of acute MR in patients with TTC. Methods and Results—Echocardiography was used to assess the mitral valve and left ventricular outflow tract (LVOT) pressure gradient in 47 patients with TTC confirmed by coronary angiography and left ventriculography. Mitral valve assessment included coaptation distance, tenting area at mid systole in the long-axis view, and systolic anterior motion of the mitral valve (SAM). Of the study patients, 12 (25.5%) had significant (moderate or severe) acute MR. In patients with acute MR versus those without acute MR, we found lower ejection fraction (31.3±6.2% versus 41.5±10.6%, P=0.001) and higher systolic pulmonary artery pressure (49.3±7.4 versus 35.5±8.9 mm Hg, P<0.001). Moreover, 6 of the 12 patients with acute MR had SAM, with peak LVOT pressure gradient >20 mm Hg (average peak LVOT pressure gradient, 81.3±35.8 mm Hg). The remaining 6 patients with acute MR revealed significantly greater mitral valve coaptation distance (10.9±1.6 versus 7.8±1.4 mm, P<0.001) and tenting area (2.1±0.4 versus 0.95±0.25 cm2, P<0.001) than those without acute MR. A multivariate analysis revealed that SAM and tenting area were independent predictors of acute MR in patients with TTC (all P<0.001). Conclusions—SAM and tethering of the mitral valve are independent mechanisms with differing pathophysiology that can lead to acute MR in patients with TTC.

Comparison of Two-Dimensional Versus Real-Time Three-Dimensional Transesophageal Echocardiography for Evaluation of Patent Foramen Ovale Morphology

The aim of this study was to elucidate patent foramen ovale (PFO) morphology and the change of PFO size using real-time 3-dimensional (3D) transesophageal echocardiography (TEE). PFO is a 3D structure, and its shape changes during the cardiac cycle. Therefore, it may be difficult to estimate accurate PFO morphology using 2-dimensional (2D) TEE. The study included 50 patients with PFO who underwent 2D and 3D TEE. PFO heights (PHs) at entrance, mid, and exit were measured by 2D and 3D TEE. Systolic and diastolic areas were also measured by 3D TEE. PH by 3D TEE was larger than that by 2D TEE (entrance 0.32 ± 0.18 vs 0.21 ± 0.15 cm, p <0.001; mid 0.25 ± 0.14 vs 0.15 ± 0.11 cm, p <0.001; exit 0.19 ± 0.11 vs 0.11 ± 0.08 cm, p <0.001). Systolic area was greater than diastolic area at each location (entrance 0.19 ± 0.17 vs 0.11 ± 0.11 cm(2), p = 0.001; mid 0.13 ± 0.11 vs 0.08 ± 0.06 cm(2), p = 0.001; exit 0.09 ± 0.09 vs 0.06 ± 0.05 cm(2), p = 0.01). Additionally, entrance area was greater than exit area in systole and diastole (systole 0.19 ± 0.17 vs 0.09 ± 0.09 cm(2), p <0.001; diastole 0.11 ± 0.11 vs 0.06 ± 0.05 cm(2), p = 0.001). There were good correlations between PH by 3D TEE and PFO area (entrance r = 0.68, mid r = 0.71, exit r = 0.78) but weak correlations between PH by 2D TEE and PFO area (entrance r = 0.62, mid r = 0.50, exit r = 0.51). In conclusion, real-time 3D TEE could provide detailed and unique information on PFO morphology.

Non-circular shape of right ventricular outflow tract: a real-time 3-dimensional transesophageal echocardiography study.

Background—The shape of right ventricular outflow tract (RVOT) has been assumed to be circular. The aim of this study was to assess RVOT morphology using 3-dimensional transesophageal echocardiography (3D TEE). Methods and Results—This prospective study included 114 patients who underwent 3D TEE. Two-dimensional (2D) TEE measured maximum and minimum RVOT diameters (RVOTD max and min) during a cardiac cycle. 3D TEE determined RVOT area (RVOTA) max and min, RVOT fractional area change, and RVOT shape index (RVOTSI; vertical/horizontal RVOTD). Cardiac output (CO) was calculated using 2D TEE, 3D TEE, and a Swan-Ganz catheter in 23 patients. All patients were classified into group 1 (RVOTSI ⩽1) or group 2 (RVOTSI >1) based on the RVOT shapes. The mean RVOTSIs were 0.84±0.21(max) and 0.82±0.20 (min). Only 17 patients (14.9%) had circular RVOT (RVOTSI: 0.95–1.05); 82 patients (71.9%) were categorized into group 1 and 32 patients (28.1%) into group 2. 2D TEE, compared with 3D TEE, underestimated RVOTA max and min (both P<0.001). CO with 3D TEE had better agreement with CO with a catheter than CO with 2D TEE (r=0.83 and 0.53, respectively). Conclusions—3D TEE revealed that RVOT geometry was not generally circular but oval with 2 different types. Because of the detailed morphological information of RVOT, 3D TEE could provide more accurate assessment of CO than 2D TEE.Background— The shape of right ventricular outflow tract (RVOT) has been assumed to be circular. The aim of this study was to assess RVOT morphology using 3-dimensional transesophageal echocardiography (3D TEE). Methods and Results— This prospective study included 114 patients who underwent 3D TEE. Two-dimensional (2D) TEE measured maximum and minimum RVOT diameters (RVOTD max and min) during a cardiac cycle. 3D TEE determined RVOT area (RVOTA) max and min, RVOT fractional area change, and RVOT shape index (RVOTSI; vertical/horizontal RVOTD). Cardiac output (CO) was calculated using 2D TEE, 3D TEE, and a Swan-Ganz catheter in 23 patients. All patients were classified into group 1 (RVOTSI ≤1) or group 2 (RVOTSI >1) based on the RVOT shapes. The mean RVOTSIs were 0.84±0.21(max) and 0.82±0.20 (min). Only 17 patients (14.9%) had circular RVOT (RVOTSI: 0.95–1.05); 82 patients (71.9%) were categorized into group 1 and 32 patients (28.1%) into group 2. 2D TEE, compared with 3D TEE, underestimated RVOTA max and min (both P <0.001). CO with 3D TEE had better agreement with CO with a catheter than CO with 2D TEE ( r =0.83 and 0.53, respectively). Conclusions— 3D TEE revealed that RVOT geometry was not generally circular but oval with 2 different types. Because of the detailed morphological information of RVOT, 3D TEE could provide more accurate assessment of CO than 2D TEE.

Impact of Energy Loss Index and Valvuloarterial Impedance in Patients with Aortic Stenosis Using Three‐Dimensional Echocardiography

Energy loss index (ELI) and valvuloarterial impedance (Zva) have been evaluated with a lack of three‐dimensional (3D) information regarding the left ventricular outflow tract (LVOT) and sino‐tubular junction (STJ). Our aim of this study is to compare the difference of ELI and Zva between two‐dimensional (2D) and 3D echocardiography.

ASSESSMENT OF THE LEFT VENTRICULAR OUTFLOW TRACT AND AORTIC VALVE AREA IN PATIENTS WITH AORTIC STENOSIS; 2-DIMENSIONAL AND 3-DIMENSIONAL ECHOCARDIOGRAPHY

The study sought to elucidate the geometry of the left ventricular outflow tract (LVOT) in patients with aortic stenosis and its effect on the accuracy of the continuity equation (CE)-based aortic valve area estimation. Forty patients with aortic stenosis who underwent 2D transthoracic

Non-Circular Shape of Right Ventricular Outflow TractClinical Perspective: A Real-Time 3-Dimensional Transesophageal Echocardiography Study

Background—The shape of right ventricular outflow tract (RVOT) has been assumed to be circular. The aim of this study was to assess RVOT morphology using 3-dimensional transesophageal echocardiography (3D TEE). Methods and Results—This prospective study included 114 patients who underwent 3D TEE. Two-dimensional (2D) TEE measured maximum and minimum RVOT diameters (RVOTD max and min) during a cardiac cycle. 3D TEE determined RVOT area (RVOTA) max and min, RVOT fractional area change, and RVOT shape index (RVOTSI; vertical/horizontal RVOTD). Cardiac output (CO) was calculated using 2D TEE, 3D TEE, and a Swan-Ganz catheter in 23 patients. All patients were classified into group 1 (RVOTSI ⩽1) or group 2 (RVOTSI >1) based on the RVOT shapes. The mean RVOTSIs were 0.84±0.21(max) and 0.82±0.20 (min). Only 17 patients (14.9%) had circular RVOT (RVOTSI: 0.95–1.05); 82 patients (71.9%) were categorized into group 1 and 32 patients (28.1%) into group 2. 2D TEE, compared with 3D TEE, underestimated RVOTA max and min (both P<0.001). CO with 3D TEE had better agreement with CO with a catheter than CO with 2D TEE (r=0.83 and 0.53, respectively). Conclusions—3D TEE revealed that RVOT geometry was not generally circular but oval with 2 different types. Because of the detailed morphological information of RVOT, 3D TEE could provide more accurate assessment of CO than 2D TEE.Background— The shape of right ventricular outflow tract (RVOT) has been assumed to be circular. The aim of this study was to assess RVOT morphology using 3-dimensional transesophageal echocardiography (3D TEE). Methods and Results— This prospective study included 114 patients who underwent 3D TEE. Two-dimensional (2D) TEE measured maximum and minimum RVOT diameters (RVOTD max and min) during a cardiac cycle. 3D TEE determined RVOT area (RVOTA) max and min, RVOT fractional area change, and RVOT shape index (RVOTSI; vertical/horizontal RVOTD). Cardiac output (CO) was calculated using 2D TEE, 3D TEE, and a Swan-Ganz catheter in 23 patients. All patients were classified into group 1 (RVOTSI ≤1) or group 2 (RVOTSI >1) based on the RVOT shapes. The mean RVOTSIs were 0.84±0.21(max) and 0.82±0.20 (min). Only 17 patients (14.9%) had circular RVOT (RVOTSI: 0.95–1.05); 82 patients (71.9%) were categorized into group 1 and 32 patients (28.1%) into group 2. 2D TEE, compared with 3D TEE, underestimated RVOTA max and min (both P <0.001). CO with 3D TEE had better agreement with CO with a catheter than CO with 2D TEE ( r =0.83 and 0.53, respectively). Conclusions— 3D TEE revealed that RVOT geometry was not generally circular but oval with 2 different types. Because of the detailed morphological information of RVOT, 3D TEE could provide more accurate assessment of CO than 2D TEE.

Non-Circular Shape of Right Ventricular Outflow Tract: A Real-Time Three-Dimensional Transesophageal Echocardiography Study

Background—The shape of right ventricular outflow tract (RVOT) has been assumed to be circular. The aim of this study was to assess RVOT morphology using 3-dimensional transesophageal echocardiography (3D TEE). Methods and Results—This prospective study included 114 patients who underwent 3D TEE. Two-dimensional (2D) TEE measured maximum and minimum RVOT diameters (RVOTD max and min) during a cardiac cycle. 3D TEE determined RVOT area (RVOTA) max and min, RVOT fractional area change, and RVOT shape index (RVOTSI; vertical/horizontal RVOTD). Cardiac output (CO) was calculated using 2D TEE, 3D TEE, and a Swan-Ganz catheter in 23 patients. All patients were classified into group 1 (RVOTSI ⩽1) or group 2 (RVOTSI >1) based on the RVOT shapes. The mean RVOTSIs were 0.84±0.21(max) and 0.82±0.20 (min). Only 17 patients (14.9%) had circular RVOT (RVOTSI: 0.95–1.05); 82 patients (71.9%) were categorized into group 1 and 32 patients (28.1%) into group 2. 2D TEE, compared with 3D TEE, underestimated RVOTA max and min (both P<0.001). CO with 3D TEE had better agreement with CO with a catheter than CO with 2D TEE (r=0.83 and 0.53, respectively). Conclusions—3D TEE revealed that RVOT geometry was not generally circular but oval with 2 different types. Because of the detailed morphological information of RVOT, 3D TEE could provide more accurate assessment of CO than 2D TEE.Background— The shape of right ventricular outflow tract (RVOT) has been assumed to be circular. The aim of this study was to assess RVOT morphology using 3-dimensional transesophageal echocardiography (3D TEE). Methods and Results— This prospective study included 114 patients who underwent 3D TEE. Two-dimensional (2D) TEE measured maximum and minimum RVOT diameters (RVOTD max and min) during a cardiac cycle. 3D TEE determined RVOT area (RVOTA) max and min, RVOT fractional area change, and RVOT shape index (RVOTSI; vertical/horizontal RVOTD). Cardiac output (CO) was calculated using 2D TEE, 3D TEE, and a Swan-Ganz catheter in 23 patients. All patients were classified into group 1 (RVOTSI ≤1) or group 2 (RVOTSI >1) based on the RVOT shapes. The mean RVOTSIs were 0.84±0.21(max) and 0.82±0.20 (min). Only 17 patients (14.9%) had circular RVOT (RVOTSI: 0.95–1.05); 82 patients (71.9%) were categorized into group 1 and 32 patients (28.1%) into group 2. 2D TEE, compared with 3D TEE, underestimated RVOTA max and min (both P <0.001). CO with 3D TEE had better agreement with CO with a catheter than CO with 2D TEE ( r =0.83 and 0.53, respectively). Conclusions— 3D TEE revealed that RVOT geometry was not generally circular but oval with 2 different types. Because of the detailed morphological information of RVOT, 3D TEE could provide more accurate assessment of CO than 2D TEE.

Non-Circular Shape of Right Ventricular Outflow TractClinical Perspective

Background—The shape of right ventricular outflow tract (RVOT) has been assumed to be circular. The aim of this study was to assess RVOT morphology using 3-dimensional transesophageal echocardiography (3D TEE). Methods and Results—This prospective study included 114 patients who underwent 3D TEE. Two-dimensional (2D) TEE measured maximum and minimum RVOT diameters (RVOTD max and min) during a cardiac cycle. 3D TEE determined RVOT area (RVOTA) max and min, RVOT fractional area change, and RVOT shape index (RVOTSI; vertical/horizontal RVOTD). Cardiac output (CO) was calculated using 2D TEE, 3D TEE, and a Swan-Ganz catheter in 23 patients. All patients were classified into group 1 (RVOTSI ⩽1) or group 2 (RVOTSI >1) based on the RVOT shapes. The mean RVOTSIs were 0.84±0.21(max) and 0.82±0.20 (min). Only 17 patients (14.9%) had circular RVOT (RVOTSI: 0.95–1.05); 82 patients (71.9%) were categorized into group 1 and 32 patients (28.1%) into group 2. 2D TEE, compared with 3D TEE, underestimated RVOTA max and min (both P<0.001). CO with 3D TEE had better agreement with CO with a catheter than CO with 2D TEE (r=0.83 and 0.53, respectively). Conclusions—3D TEE revealed that RVOT geometry was not generally circular but oval with 2 different types. Because of the detailed morphological information of RVOT, 3D TEE could provide more accurate assessment of CO than 2D TEE.Background— The shape of right ventricular outflow tract (RVOT) has been assumed to be circular. The aim of this study was to assess RVOT morphology using 3-dimensional transesophageal echocardiography (3D TEE). Methods and Results— This prospective study included 114 patients who underwent 3D TEE. Two-dimensional (2D) TEE measured maximum and minimum RVOT diameters (RVOTD max and min) during a cardiac cycle. 3D TEE determined RVOT area (RVOTA) max and min, RVOT fractional area change, and RVOT shape index (RVOTSI; vertical/horizontal RVOTD). Cardiac output (CO) was calculated using 2D TEE, 3D TEE, and a Swan-Ganz catheter in 23 patients. All patients were classified into group 1 (RVOTSI ≤1) or group 2 (RVOTSI >1) based on the RVOT shapes. The mean RVOTSIs were 0.84±0.21(max) and 0.82±0.20 (min). Only 17 patients (14.9%) had circular RVOT (RVOTSI: 0.95–1.05); 82 patients (71.9%) were categorized into group 1 and 32 patients (28.1%) into group 2. 2D TEE, compared with 3D TEE, underestimated RVOTA max and min (both P <0.001). CO with 3D TEE had better agreement with CO with a catheter than CO with 2D TEE ( r =0.83 and 0.53, respectively). Conclusions— 3D TEE revealed that RVOT geometry was not generally circular but oval with 2 different types. Because of the detailed morphological information of RVOT, 3D TEE could provide more accurate assessment of CO than 2D TEE.

Mechanisms of Acute Mitral Regurgitation in Patients With Takotsubo CardiomyopathyClinical Perspective

Background—Recent studies have suggested acute mitral regurgitation (MR) as a potentially serious complication of takotsubo cardiomyopathy (TTC); however, the mechanism of acute MR in TTC remains unclear. The aim of this study was to elucidate the mechanisms of acute MR in patients with TTC. Methods and Results—Echocardiography was used to assess the mitral valve and left ventricular outflow tract (LVOT) pressure gradient in 47 patients with TTC confirmed by coronary angiography and left ventriculography. Mitral valve assessment included coaptation distance, tenting area at mid systole in the long-axis view, and systolic anterior motion of the mitral valve (SAM). Of the study patients, 12 (25.5%) had significant (moderate or severe) acute MR. In patients with acute MR versus those without acute MR, we found lower ejection fraction (31.3±6.2% versus 41.5±10.6%, P=0.001) and higher systolic pulmonary artery pressure (49.3±7.4 versus 35.5±8.9 mm Hg, P<0.001). Moreover, 6 of the 12 patients with acute MR had SAM, with peak LVOT pressure gradient >20 mm Hg (average peak LVOT pressure gradient, 81.3±35.8 mm Hg). The remaining 6 patients with acute MR revealed significantly greater mitral valve coaptation distance (10.9±1.6 versus 7.8±1.4 mm, P<0.001) and tenting area (2.1±0.4 versus 0.95±0.25 cm2, P<0.001) than those without acute MR. A multivariate analysis revealed that SAM and tenting area were independent predictors of acute MR in patients with TTC (all P<0.001). Conclusions—SAM and tethering of the mitral valve are independent mechanisms with differing pathophysiology that can lead to acute MR in patients with TTC.

Mechanisms of Acute Mitral Regurgitation in Patients With Takotsubo CardiomyopathyClinical Perspective: An Echocardiographic Study

Background—Recent studies have suggested acute mitral regurgitation (MR) as a potentially serious complication of takotsubo cardiomyopathy (TTC); however, the mechanism of acute MR in TTC remains unclear. The aim of this study was to elucidate the mechanisms of acute MR in patients with TTC. Methods and Results—Echocardiography was used to assess the mitral valve and left ventricular outflow tract (LVOT) pressure gradient in 47 patients with TTC confirmed by coronary angiography and left ventriculography. Mitral valve assessment included coaptation distance, tenting area at mid systole in the long-axis view, and systolic anterior motion of the mitral valve (SAM). Of the study patients, 12 (25.5%) had significant (moderate or severe) acute MR. In patients with acute MR versus those without acute MR, we found lower ejection fraction (31.3±6.2% versus 41.5±10.6%, P=0.001) and higher systolic pulmonary artery pressure (49.3±7.4 versus 35.5±8.9 mm Hg, P<0.001). Moreover, 6 of the 12 patients with acute MR had SAM, with peak LVOT pressure gradient >20 mm Hg (average peak LVOT pressure gradient, 81.3±35.8 mm Hg). The remaining 6 patients with acute MR revealed significantly greater mitral valve coaptation distance (10.9±1.6 versus 7.8±1.4 mm, P<0.001) and tenting area (2.1±0.4 versus 0.95±0.25 cm2, P<0.001) than those without acute MR. A multivariate analysis revealed that SAM and tenting area were independent predictors of acute MR in patients with TTC (all P<0.001). Conclusions—SAM and tethering of the mitral valve are independent mechanisms with differing pathophysiology that can lead to acute MR in patients with TTC.