Annular Plane Systolic Excursion Research Articles

Speckle tracking analysis to evaluate the size, shape, and function of the atrial chambers in fetuses with d-transposition of the great arteries to predict the need for neonatal urgent balloon atrial septostomy.

Speckle tracking analysis was used to evaluate right (RA) and left (LA) atria size, shape and contractility to create a probability calculator to identify fetuses at risk for urgent neonatal balloon atrial septostomy (BAS). The study group consisted of 39 fetuses with D-TGA, of which 55% (N=22) required neonatal BAS and 45% (N=17) did not. The RA and LA end-diastolic areas, lengths, widths, and sphericity indices as well as global, longitudinal, and transverse contractility were measured with speckle tracking analysis. The z-scores of the measurements were compared to 200 controls. Logistic regression analysis of the computed z-score measurements was performed to separate fetuses requiring urgent neonatal atrial BAS from those who did not. The following z-score values for all fetuses with D-TGA, irrespective of whether they required neonatal BAS, that were significantly less than controls: RA base sphericity index, basal-apical length fractional shortening, fractional area change, lateral wall annular plane systolic excursion (APSE), and longitudinal reservoir strain; LA mid-chamber width, fractional shortening, ejection fraction, basal-apical length fractional shortening, atrial ejection volume, septal wall APSE, and reservoir strain. The following z-score values were significantly larger than control values: RA/LA mid-chamber width, RA/LA base width, and RA mid-chamber length. Logistic regression analysis identified the following five measurements that correctly identified 19 of 22 fetuses requiring urgent neonatal atrial BAS with a sensitivity of 86.4%, a false-positive rate of 11.8% and a positive predictive value of 90.4%: (1) LA mid-chamber transverse fractional shortening, (2) RA mid-chamber end-diastolic width, (3) RA basal-apical length fractional shortening, (4) RA mid-chamber fractional shortening, and (5) RA fractional area change. Using the measurements described in this study identified significant differences between all fetuses with D-TGA and controls, as well as identified measurements that predicted the probability of D-TGA fetuses requiring neonatal septostomy.

Systemic ventricular function in Fontan patients at rest and after exercise at altitude.

Physical activity at high altitude is expected to pose risks for patients with Fontan circulation and to impair systemic ventricular function. This study aims to determine the effect of high-altitude hypoxia on ventricular function in Fontan patients at rest and after exercise. We hypothesize that systemic ventricular function deteriorates under hypoxic conditions in Fontan patients. In this prospective study, 21 Fontan patients (NYHA class I-II) and 21 age-, gender- and body mass index-matched healthy controls were enrolled (median age 17.9 and 16.9 years). Transthoracic echocardiography was performed at rest, after peak (PE) and after continuous exercise (CE) in normoxia and hypoxia at simulated altitude (2,500 m above sea level). The effect of hypoxia on echocardiographic parameters was quantified by linear mixed-effects models and the difference between normoxia and hypoxia (Δ= hypoxia-normoxia). At rest, cardiac output (CO) estimated by outflow tract velocity time integral × heart rate and annular plane systolic excursion (APSE) were lower in hypoxia compared to normoxia in Fontan patients (CO: Δ = -12.0%, n.s.; APSE: Δ = -9.6%, p < 0.001), an increase was observed in controls (CO: Δ = 8.5%, n.s.; APSE: Δ = 2.5%, n.s.). Other parameters of systolic and diastolic function did not show relevant changes. After exercise under hypoxic conditions, Fontan patients did not show relevant deterioration of systolic function compared to normoxia. Late, active diastolic filling reflected by A-wave velocity remained unchanged in Fontan patients, but increased in controls. Under hypoxic conditions, CO and workload were higher after CE than PE in Fontan patients (CO: PE Δ = 1,530 vs. CE 1630), whereas controls showed higher work load and CO estimates after PE than CE as expected (CO: PE Δ = 2,302 vs. CE 2149). Fontan patients clinically tolerated short-term altitude exposure up to two hours and exercise and showed no consistent deterioration of systolic systemic ventricular function, but parameters of myocardial contractility, heart rate and cardiac output did not increase as observed in controls. This is likely to be multifactorial and may include intrinsic cardiac dysfunction as well as preload inadequacy and the lack of augmented atrial contraction. CE may be better tolerated than PE.

Abstract 10678: Structural and Functional Changes of the Right Ventricle in Sprague Dawley and Wistar Rat Models of Pulmonary Arterial Hypertension

Introduction: Assessment of right ventricle (RV) function and structure are essential to determine the efficacy of new PAH drugs preclinically. This study compared RV function, structure, and hemodynamics in response to monocrotaline (MCT) in Sprague Dawley (SD) and Wistar rats. Methods: SD and Wistar rats (194-243 g) were administered either 0.9% NaCl or MCT (60 mg/kg) on Day 0. On Day 23, RV function and structure were evaluated by echocardiography. On Day 24, RV pressure-volume relations were assessed, and heart and lung weights were collected. Results: MCT treatment resulted in dilated RV hypertrophy in both strains, but the magnitude of changes were different between strains. RV internal diameter during diastole (61%, p=0.0003) and systole (67%, p=0.001), RV end-diastolic (51%, p&lt;0.0001) and systolic (80%, p&lt;0.0001) area were greater in MCT/SD than MCT/Wistar. MCT/SD also showed increased right atrial area (110%, p=0.0002) vs. MCT/Wistar. Due to increased load, MCT/SD tended to develop a thicker RV free wall (22%, p&gt;0.05) than MCT/Wistar. Systolic dysfunction was observed with MCT treatment in both strains; however, the MCT/SD showed a greater decrease in RV fractional area change (-51%, p=0.009) than MCT/Wistar. The tricuspid annular velocity and annular plane systolic excursion were slightly decreased in MCT/SD compared to MCT/Wistar (p=NS). RV catheterization showed similar MCT-induced increases in RV end systolic and diastolic pressures in both strains. However, the decrease in cardiac output was more pronounced in MCT/SD (-30%, p&lt;0.0001) than in MCT/Wistar. Increase in RV weight normalized by tibia length (RV/TL) and Fulton’s Index was observed with MCT treatment; but the degree of hypertrophy was more pronounced in MCT/SD (57% RV/TL and 37% Fulton’s Index) than MCT/Wistar. Conclusions: Our results showed that while similar hemodynamic changes were observed in SD and Wistar rats in response to MCT, the magnitude of dilated RV hypertrophy and systolic impairment was exacerbated in SD vs. Wistar rats.

Cardiac function in bronchiolitis: Not only a right ventricle matter.

Extrapulmonary manifestations of bronchiolitis have been previously studied, with some identifying right ventricle (RV) diastolic/systolic dysfunction. We hypothesized that severe cases of bronchiolitis would have cardiac dysfunction resulting an increase in N-terminal pro-hormone B-type natriuretic peptide (NT-proBNP) values and worse outcomes. Therefore, the objective was to evaluate the existence of cardiac dysfunction and to determine its association with severe bronchiolitis. This prospective cohort study included children hospitalized for bronchiolitis under 1-yearold between January 2019 and March 2020. At admission, an echocardiography was performed and plasma levels of NT-proBNP were measured. To analyze outcomes, the cohort was divided into two groups based on the need for positive pressure respiratory support (PPRS), and both were compared to healthy infants. bivariant analysis, significant differences p < 0.05. One hundred eighty-one patients were included; median age was 2 months. Seventy-three patients required PPRS. Compared to controls, patients requiring PPRS showed worse RV systolic function, with lower tricuspid annular-plane systolic excursion (p = 0.002) and parameters of worse right and left diastolic function (trans-tricuspid E and A wave [p = 0.004 and p = 0.04, respectively] and tricuspid tissue doppler imaging [TDI] e' [p = 0.003], trans-mitral E and mitral TDI a' [p = 0.02 and p = 0.005, respectively]). AnNT-ProBNP greater than 3582 pg/dl predicts the need for longer necessity of PPRS in patients younger than 2 months. In addition to the expected RV systolic dysfunction, patients with severe bronchiolitis have parameters of global diastolic worse function possibly secondary to intrinsic myocardial involvement. NT-ProBNP values at admission had strong discriminatory power to predict worse outcomes.

Comparison of Myocardial Deformation by Speckle-Tracking Echocardiography and Cardiac Magnetic Resonance in Patients with Fontan Circulation: Diagnostic Algorithm.

Background:While the short- and median-term survival has improved considerably in patients with Fontan circulation, cardiac function and exercise capacity are still reduced and may deteriorate over time. Cardiac magnetic resonance (CMR) is the gold standard for the assessment of ventricular volume and function. Speckle-tracking echocardiography (STE) is a myocardial deformation technique to assess ventricular function, with promising results. The aim of our study is to validate STE and conventional echocardiography parameters and to compare them with CMR. Furthermore, we aimed to design a diagnostic algorithm applying some parameters in series for early detection of myocardial dysfunction.Materials and Methods:We performed a cross-sectional single-center study in 64 patients with Fontan circulation. Longitudinal and circumferential strain, strain rates, and conventional echocardiographic measurements were registered. Ventricular volumes and ejection fraction (EF) were obtained by CMR.Results:Seven patients presented ventricular dysfunction (EF <45% by CMR), without showing a significant correlation between STE parameters or conventional measures by echocardiography and CMR. After the application of the diagnostic algorithm with the optimal cutoff points (global longitudinal strain – 24.5%, global circumferential strain – 20%, and annular plane systolic excursion – 16.5 mm), we got a sensitivity rate and a negative predictive value of 100%. In 19 patients (40.1%), the absence of ventricular dysfunction was demonstrated without no false-negative cases.Conclusions:STE should be considered a complementary diagnostic tool in Fontan patients. These suggested parameters applied in series are a useful tool for identifying early ventricular dysfunction and for diagnostic tests improvement with a fewer CMRs in the follow-up of these patients.

Atrioventricular plane displacement versus mitral and tricuspid annular plane systolic excursion: A comparison between cardiac magnetic resonance and M-mode echocardiography.

Both echocardiography and CMR imaging are used to quantify longitudinal function. Inter-method variability for mitral (MAPSE) and tricuspid (TAPSE) annular plane systolic excursion, and variability between directly measured MAPSE and TAPSE and as based on atrioventricular plane displacement (AVPD) analysis by CMR, are, however, not known. This study, therefore, assessed inter-method variability and variability between annular plane systolic excursion and AVPD-based values in a healthy adult population. Echocardiography and CMR were performed in 111 adults (35 [32-38] years). Method comparisons were assessed with Deming regression, Bland-Altman analysis and coefficient of variation. Observer reproducibility was assessed by the concordance correlation coefficient. Echocardiography and semi-automatic CMR agreed on MAPSE (17±2mm vs. 17±2mm, p=0.1) and TAPSE (25±3mm vs. 25±3mm, p=0.5), correlated highly between methods (fitted-slope 1.22 [95% CI 1.07-1.38] and 1.12 [95% CI 0.95-1.29]) and showed low bias (0.42 [95% CI-2.05 to 2.88] and-0.18 [95% CI-4.78 to 4.43]). Intra-/inter-observer reproducibility was high for both methods for both MAPSE (echocardiography 0.96/0.86; CMR 0.87/0.85) and TAPSE (echocardiography 0.96/0.95; CMR 0.97/0.96). MAPSE (16±2mm vs. 17±2mm; p<0.001) and TAPSE (24±3 vs. 25±3mm; p<0.001) based on AVPD were similar but statistically different compared with semi-automatic CMR. Echocardiography and semi-automatic CMR have low variability and provide similar values for MAPSE and TAPSE and are thus interchangeable for follow-up studies. Lateral values based on tracked data from AVPD analysis are not clinically significantly different and could be used as a representation of annular displacement.

Annular plane systolic excursion Z-scores in evaluation of heart systolic function of fetus with heart failure

Objective To compare fetal tricuspid annular plane systolic excursion(TAPSE）Z-scores and mitral annular plane systolic excursion(MAPSE) Z-scores between fetuses with heart failure (HF) and normal fetuses, and to analysis the correlation between CVPS and annular plane systolic excursion(APSE) Z-score(sum of the TAPSE and MAPSE Z-score) in order to evaluate the ventricle systolic function and severity in fetuses with HF. Methods A total of 1012 normal fetuses and 24 fetuses with heart failure were involved. TAPSE and MAPSE were measured by free angle M-mode(FAM) echocardiography. Normal FAM-TAPSE and FAM-MAPSE Z-score models based on GA were constructed by performing a standard regression analysis followed by weighted regression of absolute residual values . Tei indexes were calculated in all fetuses with heart failure and all of them were divided into left heart failure (LHF)group and right heart failure（RHF)group by Tei index. Subsequently, FAM-MAPSE Z-scores were compared between the normal and LHF groups, FAM-TAPSE Z-scores were compared between the normal and RHF groups．FAM-APSE Z-scores (sum of the FAM-TAPSE and FAM-MAPSE Z-score) and the cardiovascular profile scores (CVPS) in 24 fetuses were calculated, the correlation was analyzed among them. Results The models used to calculate Z-score for FAM-TAPSE and FAM-MAPSE were constructed, and GA had significant correlation with them (r = 0.949, p < 0.001for all)．Compared with normal fetuses, the mean Z-scores of FAM-TAPSE and FAM-MAPSE were statistically significantly different in fetuses with HF．In the HF groups, all FAM-TAPSE and FAM-MAPSE Z-scores(22/22) were <-2. CVPS ranged from 3 to 8 (mean 5.25 out of 10) and correlated positively with FAM-APSE Z-score (r = 0.762). Conclusions The FAM-TAPSE and FAM-MAPSE Z-scores declined in fetuses with HF and they can provide quantitative evidence in evaluation of heart systolic function, FAM-APSE Z-score correlated positively with CVPS. FAM-TAPSE, FAM-MAPSE and FAM-APSE Z-scores would be markers for assessing heart systolic function and severity in fetuses with HF.

P2602Inhaled iloprost improves echocardiographic myocardial performance during exercise in heart failure with preserved ejection fraction

Abstract Introduction The pathophysiology of HFpEF is complicated and treatments that improve outcomes in HFrEF have no substantial benefits in HFpEF. Impairments in LV global longitudinal strain (GLS) and LV diastolic function parameters have been regarded as novel echocardiographic markers to predict cardiovascular events in HFpEF. Preliminary trials indicate that iloprost, an inhaled prostacyclin analougue, improves exercise hemodynamics in both patients with pulmonary artery hypertension and pulmonary hypertension associated with HFpEF. Purpose We aim to investigate the impact of inhaled iloprost on LV global longitudinal strain, LV diastolic function and RV function during exercise in HFpEF population. Methods 34 patients diagnosed with HFpEF were included with exclusion of severe pulmonary, coronary artery, valvular heart and pericardial diseases. Subjects were randomized 1:1 to inhalation of iloprost or placebo. Transthoracic echocardiography was performed at rest and after 6-minute supine bicycle exercise at 20-Watt workload. We utilized tissue speckle tracking by QLAB software to derive LV GLS and global strain rate during LV isovolumetric relaxation period (SRIVR). E/e', E/SRIVR, tricuspid regurgitation pressure gradient (TRPG), tissue Doppler imaging of RV lateral tricuspid annulus and tricuspid annular plane systolic excursion (TAPSE) were measured to evaluate changes of myocardial performance. Results LV GLS during exercise significantly enhanced after iloprost use. E/SRIVR, a novel predictor of LV filling pressure, was significantly decreased. E/e' was also lower in iloprost group by trend. Improvements in RV function and degree of pulmonary hypertension during exercise with iloprost were observed in this study. Echocardiographic myocardial function endpoints during 20-Watt excercise between iloprost and placebo groups Iloprost (N=17) Placebo (N=17) P value LV global longitudinal strain, % −4.96±1.20 −0.75±3.00 &lt;0.001 E/SRIVR, cm 206.41±113.55 454.13±262.98 0.005 E/e' mean 10.77±2.39 14.41±12.14 0.235 TAPSE, cm 2.62±0.62 2.37±0.56 0.221 TRPG, mmHg 28.37±12.47 44.25±9.29 &lt;0.001 TDI lateral tricuspid annulus, cm/s 16.41±4.61 14.77±2.92 0.222 Effects of iloprost at rest and exercise Conclusions Our study is the first to demonstrate that, in patients with HFpEF, inhaled iloprost favorably enhances LV GLS reserves, decreases LV diastolic filling load, reduces pulmonary hypertension and thereby improves RV function during exercise. Acknowledgement/Funding This work was supported in part by the National Science Council of the Republic of China, Taiwan (NSC107-2314-B-002-265-MY3)

EP11.14: Annular plane systolic excursion z‐score in evaluation of heart systolic function of fetus with heart failure

EP11.14: Annular plane systolic excursion z‐score in evaluation of heart systolic function of fetus with heart failure

Speckle Tracking of the Basal Lateral and Septal Wall Annular Plane Systolic Excursion of the Right and Left Ventricles of the Fetal Heart.

Annular plane systolic excursion (APSE) has been evaluated for the right (RV) and left (LV) ventricles using M-mode echocardiography. This study examined APSE using 2-dimensional speckle tracking (2DST) of the lateral and septal annuli of the RV and LV in normal fetuses. Two hundred normal fetuses were prospectively examined between 20 and 40 weeks' gestation, in which the end-diastolic and end-systolic lengths were measured from the apex to the insertion of the annuli into the lateral and septal walls of the RV and LV using 2DST. Subtracting the end-systolic from the end-diastolic length resulted in the APSE measurement. The APSE values from the ventricular and septal locations were regressed against biometric and gestational age independent variables, and the mean and standard deviation computed using fractional polynomial analysis. Within-subject repeated measures of variance were used to compare results within and between the right ventricular and left ventricular basal APSE values. When regressed against the independent variables the R2 for the APSE of the right ventricular lateral wall ranged from 0.39 to 0.40, the left ventricular lateral wall 0.29 to 0.31, the right ventricular septal wall 0.22 to 0.40, and the left ventricular septal wall 0.05 to 0.07. There was a significant difference (P < .001) for APSE between the right ventricular and left ventricular lateral wall and their respective septal annuli, the left ventricular and right ventricular lateral wall annuli, and the left ventricular and right ventricular septal annuli. The right ventricular and left ventricular lateral and septal wall APSE can be computed using 2DST and are associated with changing fetal biometric and age measurements.

Longitudinal strain by two-dimensional speckle tracking to assess ventricular function in adults with transposition of the great arteries: Can serial assessment be simplified?

IntroductionTransposition of the great arteries (TGA) is a rare form of congenital heart disease in which most patients reach adulthood. Right ventricular dysfunction is the most severe residual complication in long-term follow-up, both in patients treated by atrial switch and in those with congenitally corrected TGA. New echocardiographic tools such as longitudinal strain by two-dimensional (2D) speckle tracking may improve assessment of ventricular function in these patients. Methods and ResultsWe performed a retrospective analysis of echocardiograms in adult patients with TGA (26 patients with dextro-TGA – 15 treated by atrial switch and six by arterial switch – and five with congenitally corrected TGA) and in a control group of 14 healthy individuals. Right ventricular strain was significantly worse (p<0.001), as was the corresponding annular plane systolic excursion (p=0.010) in atrial switch patients, in comparison to arterial switch patients, while no differences were found in left ventricular parameters. In the overall population, systemic right ventricular parameters were significantly less negative than pulmonary right ventricular parameters, and these were less negative than in controls. Left ventricular parameters were similar across groups, except for pulmonary left ventricular strain, which was worse than in controls (p=0.008) as well as pulmonary right ventricular strain. ConclusionsAssessment of ventricular function in patients with TGA by 2D speckle tracking longitudinal strain is easy and feasible and may be a useful tool for serial follow-up. Of particular note, we found that there is also some degree of ventricular dysfunction even after re-establishment of normal connections.

Biventricular impact of mild to moderate fetal pulmonary valve stenosis.

To define the pattern of fetal echocardiographic changes associated with isolated pulmonary valve stenosis (PS) and to correlate the echocardiographic findings with neonatal outcome and the need for postnatal pulmonary valvuloplasty within the first 12 months postpartum. This was a prospective cohort study between January 2009 and October 2015 of 16 fetuses with isolated PS and 48 controls matched by gestational age at ultrasound examination (± 2 weeks) evaluated at the Fetal Cardiology Unit at BCNatal (Barcelona). Standard fetal ultrasound and comprehensive echocardiography, which included cardiovascular morphometric parameters, and systolic and diastolic functional and timing measurements, were performed in all cases. Baseline characteristics and perinatal outcome were retrieved from clinical records. Cases were followed up until 12 months of age, and admission to intensive care unit, days of hospitalization, need for prostaglandins and requirement for postnatal surgery were reviewed. Fetal PS cases were analyzed according to the need for postnatal pulmonary valvuloplasty. The study groups were similar in terms of baseline, fetal ultrasound and perinatal characteristics. Median gestational age at diagnosis of PS was 33.4 (range, 20.0-36.5) weeks. Most cases corresponded to mild or moderate PS; only three fetuses had reversed flow in the ductus arteriosus before delivery. Six (37.5%) newborns, including all three with reversed flow in the ductus arteriosus prenatally, required postnatal pulmonary valvuloplasty. Fetuses with PS presented with larger and more globular hearts, with increased myocardial wall thickness in the third trimester. Despite preserved right ventricular (RV) ejection fraction and systolic longitudinal motion, PS cases showed increased right cardiac output and signs of diastolic dysfunction, with higher ductus venosus pulsatility index (0.72 ± 0.32 vs 0.53 ± 0.16, P= 0.004) and tricuspid E/E' ratio (7.52 ± 3.07 vs 5.76 ± 1.79, P= 0.022). In addition, fetuses with PS displayed a compensatory increase in left ventricular (LV) radial and longitudinal motion, as shown by a higher ejection fraction (79.3 ± 8.23% vs 67.6 ± 11.3%, P= 0.003) and mitral annular-plane systolic excursion (5.94 ± 1.38 vs 5.0 ± 1.22 mm, P= 0.035). Finally, fetuses requiring postnatal pulmonary valvuloplasty showed a different pattern of echocardiographic findings from those not requiring valvuloplasty, with a significantly smaller RV and pulmonary valve diameter, reduced tricuspid annular-plane systolic excursion (5.08 ± 1.59 vs 8.07 ± 1.93 mm, P= 0.028), increased LV cardiac output (340 ± 16 vs 176 ± 44 mL/min/kg, P =0.003) and more pronounced signs of LV diastolic dysfunction (mitral E' velocity, 5.78 ± 0.90 vs 8.16 ± 1.58 cm/s, P= 0.008). Fetuses with PS present with more hypertrophic, larger and more globular hearts in the third trimester of pregnancy, associated with a higher right cardiac output and impaired biventricular relaxation. In addition, signs of increased LV contraction were observed. Our data suggest that RV and LV functional parameters could be useful for predicting the need for postnatal pulmonary valvuloplasty. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Does Septoplasty Improve Heart Functions of Patients With Septum Deviation in Terms of Echocardiography Findings?

The authors aimed to determine pulmonary artery pressure and right heart functions in patients with nasal septum deviation (NSD) with echocardiography (EchoCG) and compare the postoperative changes of EchoCG parameters with preoperative findings. Seventy-six patients who underwent septoplasty composed the study group. Average age of patients was 23.50 ranging between 18 and 48 years of age. There were 53 males (69.7%) and 23 females (30.3%). Mean pulmonary artery pressure, tricuspid annular-plane systolic excursion, right ventricular diameter, and e/a ratio were measured by EchoCG preoperatively and same parameters were reobtained 3 months after surgery. Mean pulmonary artery pressure reduced from 23.88 ± 6.36 to 19.80 ±3.95 mm Hg and tricuspid annular-plane systolic excursion increased from 22.36 ±3.85 to 23.57±3.00 3 months after surgery. It represented statistically significant improvement at right heart functions postoperatively (P < 0.001). Although they were not statistically significant, there was also some improvement in right ventricular diameter and e/a ratio values postoperatively. Nasal septum deviation was associated with higher PAP values, which were improved after surgery. Although at a lower extent, a negative effect of NSD on right heart functions was also suspected. Thus, treatment of NSD without delay was proposed, not only to treat the nasal symptoms but possible future cardiovascular complications as well.

Effect of 50 mg alteplase to intermediate-risk pulmonary embolism with right ventricular dysfunction

Objective: To investigate the effect of 50 mg alteplase to intermediate-risk acute pulmonary embolism (APE) with right ventricular dysfunction. Methods: From May 2011 to May 2015, a total of 73 patients with intermediate-risk APE, furthermore, right ventricular systolic pressure (RVSP)>40 mmHg and B-type natriuretic peptide (BNP)>100 ng/L, were allocated to receive 50 mg alteplase plus anti-coagulation (thrombolysis group, TG, n=35) or anticoagulation alone (control group CG, n=38) according to their will.Tricuspid annular plane systolic excursion (TAPSE), Right ventricular fractional area change (RVFAC), RVSP, BNP, CT obstruction index (CTOI) were detected at prior treatment, 1st day, 14th day, 3rd month, 6th month. The adverse events consisting of hemodynamic decompensation (within 14 days), mortality, bleeding, recurrent pulmonary embolism (PE), RVSP>40 mmHg (at 6th month) were recorded. Results: At prior treatment, TAPSE, RVFAC, RVSP, BNP and CTOI between TG and CG were (10.9±1.4) vs (11.4±1.2) mm, (27.8±3.9)% vs (28.1±4.1)%, (55.6±7.9) vs (54.6±8.4) mmHg, (491±76) vs (482±71) ng/L and (23.4±4.2)% vs (23.7±4.5)%. There was not statistical difference between two groups (all P>0.05). From 1st to 14th day, these indexes had better and faster improvement in TG than CG. At 6th month, TAPSE, RVFAC, RVSP and CTOI between two groups were (17.5±1.3) vs (15.4±1.1) mm, (49.4±3.9)% vs (46.0±2.8)%, (15.8±2.2) vs (17.8±4.2) mmHg, and (1.7±1.6)% vs (4.0±3.0)% (all P<0.05), BNP was (66±13) vs (71±15) ng/L (P>0.05). From prior treatment to 6th month, the tendency of variation of these index in TG was better than CG (P<0.05). From prior treatment to 14th day, 3 cases of hemodynamic decompensation occurred in CG, 0 case in TG.During treatment, there were not cases of death and major bleeding. At 6th month, there were 4 cases of RVSP>40 mmHg in CG, while 0 case in TG (P=0.048). Conclusion: 50 mg alteplase can reduce the thrombus in pulmonary artery, improve right ventricular function quickly, and decrease the risk of elevated RVSP in the long term, for the patients with intermediate-risk APE.

Correspondence of Myocardial Strain with Torrent-Guasp’s Theory. Contributions of New Echocardiographic Parameters

Background: Strain, assessed by speckle tracking echocardiography, may be used to evaluate left ventricular mechanics and could establish reference values together with new indices of myocardial function. Objective: The aim of this study was to demonstrate the correspondence of echocardiographic strain values with TorrentGuasp’s single band theory. Methods: A prospective observational study was conducted in 54 healthy volunteers. The three apical projections were used to determine longitudinal strain. Radial strain, circumferential strain and rotation were assessed in transverse planes at the level of the mitral valve, the papillary muscles and the apex. Results: Mean age was 52±10.1 years. Global left ventricular longitudinal strain was -20.8%±2.4%. Postsystolic longitudinal strain mainly affects interventricular septal segments. Radial strain was 36.5%±10.7%, with basal values prevailing over apical ones, extending its duration to the early phase of diastole. Circumferential strain was -20.8%±3.8%, with larger values towards the apex. Twist was 18.4°±6°, torsion 2.2°±0.8°/cm and the torsion index (twist/mitral annular plane systolic excursion) 13.1°±4.4°/cm. The combined strain index includes the “strain product” (-387°±147° × %), and the “strain index” (-0.9°±0.3°/%) calculated as twist × longitudinal strain and twist/longitudinal strain, respectively. Conclusions: New strain parameters may be useful in the study of ventricular mechanics. The anatomical arrangement described by the myocardial band theory is echocardiographically supported by the presence of larger radial strain at the basal-medial level (prevalence of transverse fibers), while the variable arrangement of oblique fibers are responsible for longitudinal strain, circumferential strain and ventricular torsion.

Cardiac Function After Multimodal Breast Cancer Therapy Assessed With Functional Magnetic Resonance Imaging and Echocardiography Imaging

Breast intensity modulated radiation therapy (IMRT) reduces high-dose heart volumes but increases low-dose volumes. We prospectively assessed heart changes after 3D conformal RT (3DCRT) and IMRT for left-sided breast cancer. Heart dose was analyzed individually, 3DCRT patients were moderately exposed, and IMRT was performed only in patients with unacceptably high heart doses upon 3DCRT planning. In 49 patients (38 patients received 3DCRT; 11 patients received IMRT; and 20 patients received neoadjuvant or adjuvant chemotherapy) magnetic resonance imaging (MRI) and echocardiography were performed before and at 6, 12, and 24 months after treatment. Mean heart dose for IMRT was 12.9 ± 3.9 Gy versus 4.5 ± 2.4 Gy for 3DCRT. Heart volumes receiving >40 Gy were 2.6% (3DCRT) versus 1.3% (IMRT); doses were >50 Gy only with 3DCRT. Temporary ejection fraction (EF) decrease was observed on MRI after 6 months (63%-59%, P=.005) resolving at 24 months. Only 3 patients had pronounced largely transient changes of EF and left ventricular enddiastolic diameter (LVEDD). Mitral (M) and tricuspid (T) annular plane systolic excursion (MAPSE and TAPSE) were reduced over the whole cohort (still within normal range). After 24 months left ventricular remodeling index decreased in patients receiving chemotherapy (0.80 vs 0.70, P=.028). Neither wall motion abnormalities nor late enhancements were found. On echocardiography, in addition to EF findings that were similar to those on MRI, global strain was unchanged over the whole cohort at 24 months after a transient decrease at 6 and 12 months. Longitudinal strain decreased in the whole cohort after 24 months in some segments, whereas it increased in others. Until 24 months after risk-adapted modern multimodal adjuvant therapy, only subclinical cardiac changes were observed in both 3DCRT patients with inclusion of small to moderate amounts of heart volume in RT tangents and in the patients treated with IMRT and reduced high-dose heart exposure.

A fetal cardiovascular score to predict infant hypertension and arterial remodeling in intrauterine growth restriction

Intrauterine growth restricted (IUGR) fetuses experience cardiovascular remodeling that persists into infancy and has been related to cardiovascular outcomes in adulthood. Hypertension in infancy has been demonstrated to be a strong risk factor for later cardiovascular disease. Close monitoring together with dietary interventions have shown to improve cardiovascular health in hypertensive children; however, not all IUGR infants show increased blood pressure. We evaluated the potential of fetal echocardiography for predicting hypertension and arterial remodeling in 6-month-old IUGR infants. One hundred consecutive IUGR and 100 control fetuses were observed into infancy. Fetal assessment included perinatal Doppler imaging, cardiac morphometry, ejection fraction, cardiac output, isovolumic relaxation time (IVRT), tricuspid annular-plane systolic excursion (TAPSE), and tissue Doppler imaging. Infant hypertension and arterial remodeling were defined as mean blood pressure of >95th percentile together with aortic intima-media thickness of >75th percentile at 6 months of age. Odds ratio were obtained for fetal parameters that were associated with infant outcomes. Fetal TAPSE, right sphericity index, IVRT, and cerebroplacental ratio were the strongest predictors for postnatal vascular remodeling. A cardiovascular risk score that was based on fetal TAPSE, cerebroplacental ratio, right sphericity index, and IVRT was highly predictive of infant hypertension and arterial remodeling (areaunder the curve, 0.87; 95% confidence interval, 0.79-0.93; P< .001). Fetal echocardiographic parameters identify a high-risk group within the IUGR fetuses who could be targeted for early screening of blood pressure and other cardiovascular risk factors and for promoting healthy diet and physical exercise.

Evaluation of Cardiac Functions and Atrial Electromechanical Delay in Children With Adenotonsillar Hypertrophy

Deterioration of the right ventricular (RV) functions and the increase in the pulmonary arterial pressure (PAP) of children with moderate to severe adenotonsillar hypertrophy (ATH) have been well described. In addition to these complications, this study aimed to investigate the influence of ATH on the conduction system. The study investigated 46 patients with a diagnosis of ATH and 46 healthy control subjects. Conventional echocardiography, P-wave dispersion (Pd), tissue Doppler imaging (TDI) findings, and atrial electromechanical delay (AED) were compared between the patients and the control subjects before and after adenotonsillectomy. The maximum P-wave duration and Pd were significantly higher in the patients than in the control subjects (p < 0.001). The patient group showed significantly greater RV end-diastolic dimension (p = 0.01), right atrial area (p < 0.001), and mean PAP (p = 0.03) but lower E/A ratios for the mitral (p = 0.04) and tricuspid (p = 0.01) valves and a shorter pulmonary flow trace acceleration time (p = 0.03). The tricuspid annular-plane systolic excursion was similar between these groups (p = 0.21). In the patient group, TDI studies showed significantly lower E'/A' ratios for the tricuspid lateral (p = 0.006) and mitral septal (p = 0.003) segments than in the control group. The myocardial performance index was lower for the mitral lateral, mitral septal, and tricuspid lateral segments in patient group (p < 0.001). Similarly, AED was prolonged in the patient group at all three segments (p < 0.001). Also, the patient group showed a significantly longer interatrial (p = 0.03) and intraatrial (p = 0.04) electromechanical delay. However, all the electro- and echocardiographic parameters were similar between the patients and the control subjects after adenotonsillectomy (p > 0.05). The prolongations in P-wave duration, Pd, and inter- and intraatrial electromechanical delays were first shown in this population. The cardiac changes induced by ATH-associated hypoxia may facilitate arrhythmias during the long term.

Comparison of late gadolinium enhancement patterns in different forms of cardiac amyloidosis

Background Cardiac involvement is common in different forms of amyloidosis and associated with limited survival. We aimed to use gadolinium (GAD) contrast-enhanced cardiac magnetic resonance imaging (CE-CMR) to characterize CE-CMR patterns that are related to the different forms of amyloidosis. Methods In total, 115 patients (70 male, 45 female; mean age 60.7 ±1.2 years) with different forms of amyloidosis (AL n= 63, TTR n=52) were evaluated by evaluated by VectorECG gated 1.5T whole-body CMR (Achieva Intera ® Philips Medical Systems, Best, the Netherlands) and included SSFP and CE-CMR 2-,3-,4-chamber and shortaxis planes. EDV, ESV, EF and myocardial mass were analyzed on a standard workstation. Longitudinal function was assessed by mitral (MAPSE) and tricuspid (TAPSE) annular plane systolic excursion. CE-CMR patterns were analyzed qualitatively (subepicardial, subendocardial, patchy) and semi-quantitatively (absent = 0, weak = 1, moderate = 2, severe = 3) in a modified 16 segment AHA model (maximal sum 48) of the left ventricle. Univariate and multivariate analysis were performed to define predictors of survival. Results Patients with TTR amyloidosis were significantly older and had lower TAPSE (14.6±0.9 mm vs. 17.3±0.9 mm; p<0.05) as compared to patients with AL. Both cohorts did not differ in LV mass, LV ejection fraction, and MAPSE. CE-CMR was observed in 107 (93%) of the patients (AL n=59, 93.7%; TTR n=48, 92.3%). There was no difference between both forms of amyloidosis concerning sum of CE-CMR in the 16 segments by semiquantitative analysis (AL 25.8±2.2; TTR 28.6±2.2). In each of the 16 LV segments more severe CE-CMR was associated with an increase of LV mass as well as a decrease of LV ejection fraction, MAPSE and TAPSE, respectively (p<0.001). In TTR patients a more intensive CE-CMR was found in the subepicardial layer of the basal anterolateral (p<0.001), inferolateral (p<0.001) and of the midventricular inferolateral segment (p<0.001) as compared to AL patients. During mean survival of 34.2±2.4 months there were 49 fatal events (death n=33; heart transplant n=16). Survival of AL patients was significantly worse as compared to TTR patients (p<0.05; logrank 6.225). In AL patients presence of subepicardial, subendocardial and patchy CE-CMR, LV mass, MAPSE, and TAPSE, but not LV ejection fraction, CE-CMR of LA, RA, RV or interatrial septum were predictors of survival by univariate analysis. By multivariate analysis subendocardial and patchy CE-CMR as well as LV mass were independent predictors of survival. Conclusions Prevalence of CE-CMR is high and appears to be associated with the severity of cardiac dysfunction in different forms of cardiac amyloidosis. Survival of patients with AL amyloidosis was worse as compared to TTR amyloidosis. Besides LV mass subendocardial and patchy CE-CMR were independent predictors of survival in patients with AL amyloidosis.

Non-invasive risk stratification of patients with TTR amyloidosis

Methods 30 patients (21 male, 9 female; median age 69.5 years) with diagnosis of TTR amyloidosis (wild-type n=13, hereditary n=17) were evaluated by cardiac MRI (CMR; Achieva Intera Philips Medical Systems, Best, The Netherlands), and Technetium-DPD scintigraphy. EDV, ESV, EF and myocardial mass were analyzed on a standard workstation (Philips Viewforum). Longitudinal function was assessed by mitral (MAPSE) and tricuspid (TAPSE) annular plane systolic excursion. Atrial septum thickness was measured on SSFP-4 chamber views. Gadolinium contrast-enhanced CMR (CE-CMR) was assessed semi-quantitatively (absent=0, weak=1, moderate=2, severe=3) in an AHA modified 16 segment model of the left ventricle as well as for the right/left atrium and right ventricle. Nuclear DPDretention was assessed semi-quantitatively using a region of interest technique by comparison of counts in the heart at 3 hours after injection with whole body counts at 5 min after injection.