Apical 4-chamber View Research Articles

Impact of right ventricular dyssynchrony on left ventricular performance in patients with pulmonary hypertension

Pulmonary hypertension has been associated with right ventricular (RV) dyssynchrony which may induce left ventricular (LV) dysfunction and dyssynchrony through ventricular interdependence. The present study evaluated the influence of RV dyssynchrony on LV performance in patients with pulmonary hypertension. One hundred and seven patients with pulmonary hypertension (age 63 ± 14 years, systolic pulmonary arterial pressure 60 ± 19 mmHg) and LV ejection fraction (EF) >35% were evaluated. Ventricular dyssynchrony was assessed with speckle tracking echocardiography and defined as the standard deviation of the time to peak longitudinal strain of six segments of the RV (RV-SD) and the LV (LV-SD) in the apical 4-chamber view. Mean RV-SD and LV-SD assessed with longitudinal strain speckle tracking echocardiography were 51 ± 28 and 47 ± 21 ms, respectively. The patient population was divided according to the median RV-SD value of 49 ms. Patients with RV-SD ≥49 ms had significantly worse NYHA functional class (2.7 ± 0.7 vs. 2.3 ± 0.7, p = 0.004), RV function (tricuspid annular plane systolic excursion: 16 ± 4 vs. 19 ± 4 mm, p < 0.001), LVEF (50 ± 10 vs. 55 ± 8%, p = 0.001), and larger LV-SD (57 ± 18 vs. 36 ± 18 ms, p < 0.001). RV-SD significantly correlated with LV-SD (r = 0.55, p < 0.001) and LVEF (r = -0.23, p = 0.02). Multiple linear regression analysis showed an independent association between RV-SD and LV-SD (β = 0.35, 95%CI 0.21-0.49, p < 0.001). RV dyssynchrony is significantly associated with LV dyssynchrony and reduced LVEF in patients with pulmonary hypertension.

Accurate Assessment of Aortic Stenosis

Aortic valve (AV) stenosis is one of the most common valvular diseases and is the third most common cardiovascular disease in developed countries. It occurs in ≈2.8% of patients ≥75 years of age and can occur because of degenerative calcification and congenital valvular defects such as bicuspid AVs or rheumatic disease.1–3 Calcific aortic stenosis (AS) is associated with increased leaflet stiffness and a narrowed AV orifice, resulting in increased pressure gradients across the valve. The presence of a bicuspid AV significantly increases the risk of AS.4 The natural history of AS is a prolonged asymptomatic period, with progressive reduction of the AV orifice area due to sclerosis initially, culminating in calcific AS. This is accompanied by a corresponding increase in the transaortic pressure gradient (Δ P ) and myocardial pressure overload. Through the preload reserve, the left ventricle (LV) compensates for the increased workload until the sarcomeres stretch to their maximum diastolic length. Once the preload reserve is exhausted, increases in afterload are accompanied by a reduction in stroke volume (SV), resulting in afterload mismatch. Ultimately, this causes LV hypertrophy, associated with an enlargement of cardiac myocytes and increased LV wall thickness.5 Initial diagnosis of AS typically occurs during routine physical examination with the presence of a heart murmur, click, or other abnormal sounds, but undiagnosed patients may experience the onset of severe symptoms such as angina, syncope, and heart failure. Without intervention, patient mortality typically occurs within 5 years of the onset of symptoms.6–11 Multiple studies and reviews have focused on the clinical aspects of this disease, including disease progression, markers of disease severity, treatment guidelines, and outcomes.1–3,6,12–16 Very few reviews have focused on the hemodynamic principles underlying AS and on comparing data obtained across different …

Clinical role of atrial arrhythmias in patients with arrhythmogenic right ventricular dysplasia.

The clinical role of atrial fibrillation/atrial flutter (AF-AFl) and variables predicting these arrhythmias are not well defined in patients with arrhythmogenic right ventricular dysplasia (ARVD). We hypothesized that transthoracic echocardiography (TTE) and 12-lead electrocardiography (ECG) would be helpful in predicting AF-AFl in these patients. METHODS AND RESULTS: ECGs and TTEs of 90 patients diagnosed with definite or borderline ARVD (2010 Task Force Criteria) were analyzed. Data were compared in (1) patients with AF-AFl and (2) all other patients. A total of 18 (20%) patients experienced AF-AFl during a median follow-up of 5.8 years (interquartile range 2.0-10.4). Kaplan-Meier analysis revealed reduced times to AF-AFl among patients with echocardiographic RV fractional area change <27% (P<0.001), left atrial diameter ≥24.4 mm/m(2)(parasternal long-axis, P=0.001), and right atrial short-axis diameter ≥22.1 mm/m(2)(apical 4-chamber view, P=0.05). From all ECG variables, P mitrale conferred the highest hazard ratio (3.37, 95% confidence interval 0.92-12.36, P=0.067). Five patients with AF-AFl experienced inappropriate implantable cardioverter-defibrillator (ICD) shocks compared with 4 without AF-AFl (36% vs. 9%, P=0.03). AF-AFl was more prevalent in heart-transplant patients and those who died of cardiac causes (56% vs. 16%, P=0.014). AF-AFl is associated with inappropriate ICD shocks, heart transplantation, and cardiac death in patients with ARVD. Evidence of reduced RV function and atrial dilation helps to identify the ARVD patients at increased risk for AF-AFl.

Myocardial strain analysis in patients with Heart Failure with preserved Ejection Fraction using bright blood cine MR images: A comparison with speckle-tracking echocardiography

Background Changes in myocardial strain parameters is of interest in patients with heart failure as an objective measure of disease severity. Speckle-tracking echocardiography (STecho) is the accepted standard of reference for myocardial strain analysis given superior temporal resolution; however, difficult acoustic windows and limited contrast to noise resolution can limit strain analysis. Preliminary work using deformation field analysis at steady state free precession (SSFP) cine MR imaging has shown that strain analysis at CMR is similar between conventional and highly accelerated GRAPPA cine acquisitions. The purpose of this study is to compare the strain values in patients with heart failure and preserved ejection fraction (HFpEF, left ventricular ejection fraction >50%) at SSFP cine MRI with ST-echo. Methods Retrospective analysis of Cardiac MR and echocardiographic images from 15 patients (5 men, avg age 61.2 yrs) with HFpEF. Cardiac MR images were obtained at 1.5 T (MAGNETOM Avanto, Siemens Medical Systems, Erlangen, AG) using GRAPPA factor 2 acceleration (temp res = 39.2 msec, spatial res = 1.5 × 1.5 mm, thickness = 6 mm). Myocardial strain analysis at Cardiac MR was performed using prototype software calculating Lagrangian strain from deformation field analysis (Siemens Corp, Corporate Technology, Princeton, NJ). Transthoracic echocardiography exams included apical 4-chamber and mid-ventricular short axis views. Left ventricular (LV) mid ventricular average and peak systolic radial and circumferential strains as well as longitudinal strain data was calculated. Peak and average right ventricular (RV) longitudinal strain was also obtained. CMR and ST-Echo derived strain indices were compared using the Pearson correlation. Inter and intraobserver variance was assessed for CMR-derived RV and LV longitudinal strain analysis using the intraclass correlation coefficient (ICC). Results

Anteromedial Approach to Assess the Right Heart on Echocardiography

n today’s ultrasound community, sonographers sometimes forget about the extra steps we can take to improve a patient’s end result while visiting our lab. How many times have we called a patient back to reassess a valve lesion or to look at pressures that were uninterpretable? Let us not be afraid to manipulate our technical ability to provide the absolute best in imaging. The right heart is difficult to image with echocardiography because of the location, size, and available windows (Figure 1). The traditional apical 4-chamber view allows for a direct, parallel image of the left ventricle and atrium. However, trying to maneuver the probe from this particular area may only bring in more lung artifacts or decrease the appropriate angle we were trying to achieve. Right ventricular inflow patterns, tissue Doppler imaging, tricuspid annular plane systolic excursion, and tricuspid regurgitation interrogation can be of important use in determining a patient’s care plan, given the appropriate angles. We must ask ourselves, are we doing everything we can to provide the necessary information to the reading physician? As a veteran cardiac sonographer, I am compelled to pay close attention to the left ventricle, as it is the “main” pumping chamber of the heart. In this case, we will go out of our way, in difficult cases, to give the reading physician the best we have so the physician might see the endocardium a little clearer. Sonographers must give the physician this information to assess numerous pathologic questions. The reading physician should be given the same opportunity on the right side of the heart. Congestive heart failure, hypertension, valve lesions, and congenital heart defects affect the right side as well. How many patients have had complications because a rightsided congenital defect was overlooked? In most cases, the sonographer can easily slide the probe medially from the traditional 4-chamber view. Looking at the monitor, the atria will be seen moving to the left of the screen, while the apex stays somewhat midline. To improve the parallel flow angle, move anteriorly one rib space if needed (Figure 2). Traditionally, foreshortening the 4-chamber view is frowned upon; however, this movement improves the visualization of this particular area of the heart. Cardiologists are looking to assess right ventricular hypertrophy, tricuspid valve lesions, new findings of congenital defects or ones that might have been missed, pacemaker/defibrillator leads (including infection of the leads), and more.1 One of the most common mistakes made in the field today is underesAddress correspondence to James Michael Rampoldi, RDCS, RVT, The Heart Hospital of Baylor Plano, Center for Advanced Cardiovascular Care, 4716 Alliance Blvd, Pavilion II, Suite 300, Plano, TX 75093 USA. E-mail: james.rampoldi@baylorhealth.edu I

Is MRI the Preferred Method for Evaluating Right Ventricular Size and Function in Patients With Congenital Heart Disease?

Is MRI the Preferred Method for Evaluating Right Ventricular Size and Function in Patients With Congenital Heart Disease?

Congenital Left Ventricular Diverticulum

A physician in practice referred a 52-year-old woman to our hospital for a closer examination of systolic murmur. She reported nothing particular. Auscultation showed ejection-type murmur of Levine 2/VI maximally heard at the fourth left sternal border that seemed to be functional. ECG and chest x-ray film showed no abnormal findings. To confirm the cause of systolic murmur, echocardiography was performed. Routine echocardiography indicated that the sizes and functions of both left and right ventricles and valvular functions were normal, so we diagnosed her systolic murmur as functional. Figure 1 shows apical 2-chamber views of a B-mode echocardiogram. As shown in Figure 1A (Movie I in the …

Predictive value of atrial electromechanical delay for atrial fibrillation recurrence

We investigated the predictive value of atrial electromechanical delay (AEMD) for recurrence of atrial fibrillation (AF) at 1-month after cardioversion. Seventy-seven patients with persistent AF were evaluated and finally 50 patients (12 men, 38 women) were included. All patients underwent transthoracic electrical DC cardioversion under amiodarone treatment. AEMD was measured as the time interval from the onset of the P wave on electrogram (ECG) to the beginning of late diastolic wave (Am) from the ventricular annulus and atrial walls on tissue Doppler imaging, in the apical 4-chamber view 24 h after cardiversion. P wave maximum-duration (Pmax), P wave minimum-duration (Pmin) and P wave dispersion-duration (Pdis) were calculated on the 12-lead ECG at 24-h postcardioversion. We followed the heart rate and rhythm by 12-lead ECG at 24-h, 1-week and 1-month. At 1-month follow-up after cardioversion, 28 (56%) patients were in sinus rhythm (SR), whereas 22 (44%) patients reverted to AF. The AEMD durations were longer in AF group than SR group (p < 0.001) and were signifi cantly correlated with Pmax and Pdis (p < 0.001 for both). For AF recurrence; duration of AF, left atrial (LA) diameter, maximum LA volume index, mitral A velocity and LA lateral AEMD were significant parameters in univariate-analysis, however LA lateral AEMD was the only significant parameter in multivariate-analysis (OR: 1.46; 95% CI 1.02-2.11; p = 0.03). Our results suggest that AEMD is associated with an increased risk of recurrence of AF within 1-month. These data may have implications for the identification of patients who are most likely to experience substantial benefit from cardiversion therapy for AF.

Abstract 19141: Natural History of Tricuspid Annulus and Right Atrial Remodeling in Permanent Atrial Fibrillation

Background: The natural history of tricuspid annulus and right atrial (RA) remodeling in patients with permanent atrial fibrillation (AF) has not been assessed. We aimed to determine the rate of change in tricuspid annulus diameter and RA volume in patients with permanent AF. Methods: This cohort study included 160 patients with a history of permanent AF who had at least 2 transthoracic echocardiograms performed between 2005 and 2010 at Vancouver General Hospital in British Columbia. Patients with structural valve disease at onset, congenital heart disease, and patients with more than mild-moderate tricuspid or mitral regurgitation were excluded from analyses. The tricuspid annulus diameter, defined as the distance between the points of attachment of the anterior and septal tricuspid leaflets from the apical 4-chamber view, was measured during end-systole and end-diastole. Maximal RA size was measured in terms of RA volume using single plane Simspon’s method from 4 chamber view. Linear mixed effects modelling was used in analyzing the changes in measurements over time. Results: Of the 160 subjects included in this analysis, 100 were men (62.5%). The mean age at study entry was 74±10 yrs. The median number of echocardiographic studies performed was 3 (range 2 - 6). All 160 patients showed progressive increase in tricuspid annulus diameter over time. There was a significant increase in tricuspid annulus diameter at end-systole and end-diastole over a mean follow up time of 3.2 ± 2.8 years. Respectively, the increase was 0.68 mm/ year, 95% CI 0.232 -1.02, P=0.0027) and end-diastole 0.63 mm/year, 95% CI 0.182-0.93, P=0.0015). Mean RA volume increased from a mean of 39 mL/m2 to 81 mL/m2 for the cohort, or 13 mL/m2 per year, which was significantly greater than the increase in left atrial volume (10 mL/m2 per year, P&lt;0.001). Conclusions: Permanent AF was associated with significant increase in tricuspid annulus diameter and RA volume over time. The rate of changes appeared greater on the right side than on the left. How these differential changes relate to the frequent findings of right heart failure in these patients warrant further investigations.

Abstract 19185: Remodeling of Mitral Annulus and Left Atrium in Permanent Atrial Fibrillation: Relationship to Severity of Mitral Regurgitation

Background: Left atrial (LA) size increases in atrial fibrillation (AF). How changes in mitral annulus and atrial volume over time relate to severity of mitral regurgitation (MR) is unknown. Methods: This cohort study included 160 patients with a history of permanent AF who had at least 2 transthoracic echocardiograms (TTE) performed between 2005 and 2010 at Vancouver General Hospital (British Columbia, Canada). Patients with structural mitral valve disease, congenital heart disease, more than mild-moderate mitral/tricuspid regurgitation on their first TTE were excluded from analyses. LA volume was determined using biplane area-length method, averaged over 3 cardiac cycles. The mitral annulus diameter (MAD), defined as the distance between the hinge points of the anterior and posterior mitral leaflets from the apical 4-chamber view, was measured during end-systole and end-diastole. Linear mixed effects modeling was used in analyzing the above measurements for change over time. Mitral regurgitation was classified into 3 grades (mild, moderate, or severe) using standard color Doppler and PISA easurements where available. Results: Of the 160 subjects included in this analysis, 100 were men (62.5%). The mean age at study entry was 74±10 years. The median number of TTE performed was 3 (range 2 - 6). All 160 patients showed a progressive increase in MAD over time. There was a significant increase in MAD at end-systole and end-diastole over a mean follow-up of 3.2 ± 2.8 years; the increases were 0.48 mm/year (95% CI 0.124 -0.75, P=0.0037) and 0.45 mm/year (95% CI 0.102-0.716, P=0.0029) respectively. LA volume increased from a mean of 43 mL/m2 to 75 mL/m2 for the cohort, or 10 mL/m2 per year. Adjusting for age, sex, and left ventricular ejection fraction, an increase in MR severity by at least 1 grade was strongly and independently associated with an increase in MAD. A 15% increment in MAD was associated with an increase in MR severity by 1 grade. Conclusion: Permanent AF was associated with significant increases in MAD and LA volume over time. Severity of MR also significantly increased over time, and was independently related to the change in MAD. Further investigations as to whether this represents a mechanism for left heart failure in patients with permanent AF are warranted.

Clear Morphological Depiction of Cor Triatriatum in a Child by Transthoracic 3-Dimensional Echocardiography

A 3-year-old boy had a history of cor triatriatum, which was diagnosed incidentally when he was 1 year old during workups for failure to thrive and funnel chest. Initial echocardiographic evaluation revealed no evidence of obstruction through the orifice (mean pressure gradient, 3 mm Hg). However, progressive flow obstruction was noted at follow-up. At 3 years of age, 2-dimensional echocardiography at the apical 4-chamber view demonstrated a membrane-like structure traversing the left atrium (LA) (Figure 1A; see Movie I in the online-only Data Supplement). Doppler echocardiography revealed a mean pressure gradient of 8.9 mm Hg across the orifice of this membrane (Figure 1B). However, depiction of the relationships between this membrane and the surrounding structures was not clear. Therefore, transthoracic 3-dimensional echocardiography (3DE) was performed (iE33; Philips, Andover, MA) with an X-7 matrix array transducer. The 3DE images cropped from the posterior and superior aspects of the LA toward the atrioventricular groove clearly showed that this membrane extended from the fossa ovalis area of the atrial septum to the LA free …

Acquired Fontan Physiology Secondary to Acute Mechanical Tricuspid Valve Failure in a Patient With Massive Right Heart Enlargement and Ebstein’s Anomaly

A 25-year-old man with Ebstein’s anomaly and a secundum atrial septal defect had a mechanical tricuspid valve replacement (St. Jude 31-mm valve) and atrial septal defect closure when he was 15 years old. He was under long-term specialist follow-up and had recently been admitted with symptoms and signs of right heart failure secondary to new onset atrial flutter. He was direct-current cardioverted and commenced on ramipril and metoprolol. He then went to have an electrophysiological study and successful atrial flutter ablation. At review 6 months later he reported good exercise tolerance and was now able to play 18 holes of golf, whereas previously he could only manage 9 holes. However, he commented that since the electrophysiological procedure he had been unable to hear his prosthetic valve clicks. On clinical examination he was not cyanosed, the jugular venous pressure was elevated at 4 cm without prominent V waves, there was a soft first heart sound, no audible mechanical valve clicks, and a pansystolic murmur. There were no signs of heart failure or peripheral edema. An electrocardiogram demonstrated sinus rhythm, right axis deviation, first-degree heart block, and right bundle-branch block with QRS duration of 200 ms. Echocardiography and fluoroscopy (Figure 1) showed that the leaflets of the …

Quantitation of Fetal Heart Function With Tissue Doppler Velocity Imaging—Reference Values for Color Tissue Doppler Velocities and Comparison With Pulsed Wave Tissue Doppler Velocities

Quantitative assessment of fetal heart function has been difficult. Increasingly, tissue Doppler imaging (TDI) is used to measure fetal cardiac function noninvasively. There are two principal techniques, spectral pulsed wave (PW) TDI and color TDI (CTDI). Published reference values for fetal myocardial velocities are based on spectral PW TDI only. However, previous phantom, adult, and animal studies have shown that PW TDI velocities are systematically higher than CTDI velocities. There are no fetal studies so far. We hypothesized that myocardial velocities derived by PW TDI and CTDI are significantly different in the fetus. This prospective observational study included 91 fetuses (gestational age 28.6 ± 6.6 weeks; range 19-40 weeks) seen for routine prenatal ultrasound. From apical 4-chamber views, tricuspid ring (right ventricle), lateral and septal mitral ring were sampled by PW TDI and CTDI. Bland-Altman analysis was used for comparisons. PW and CTDI S' velocities correlated strongly in all three cardiac segments (r = 0.6 to 0.9; P < 0.01). There was a systematic bias toward higher velocities with PW TDI versus CTDI (bias 0.96 cm/s; 95% CI 1.08-0.85 cm/s). However, the strength of the correlation and bias varied depending on the region of the fetal heart sampled. PW TDI and CTDI velocity measurements are feasible in the fetus and correlate well. However, PW TDI velocities are higher than CTDI velocities with significant regional variation. This precludes a mathematical conversion of PW to CTDI in vivo. As PW TDI and color TDI vary, different reference values for fetal CTDI velocities were generated.

Echocardiographic, Histopathologic, and Surgical Findings in Staphylococcus lugdunensis Mitral Valve Endocarditis After Prostate Biopsy

A 66-year-old white man presented to the emergency department with a 4-day history of progressive dyspnea, cough, and hemoptysis. The patient was known to have mitral valve prolapse confirmed by transthoracic echocardiogram, performed 9 months before his present admission. The transthoracic echocardiogram had shown a myxomatous mitral valve with prolapse of the P2 scallop and severe eccentric mitral regurgitation (MR) that was anteriorly directed. The mitral regurgitant fraction using the volumetric method was 69%. The left ventricular (LV) end diastolic dimension was 4.8 cm, and the LV end systolic dimension was 3.3 cm, both within normal limits. The LV systolic function was normal with ejection fraction (modified Simpson’s rule) of 58%. The right ventricular dimensions were normal (apical 4-chamber view: long axis, 7.2 cm; midshort axis, 2.2 cm; inflow short axis, 2.5 cm). The right ventricular systolic function was normal. The peak pulmonary artery systolic pressure was 30 mm Hg, with estimated right atrial pressure of 5 mm Hg. The patient had a transrectal prostate biopsy done to rule out carcinoma a few weeks before his presentation to the emergency department. On examination, he was hypotensive (blood pressure, 96/61 mm Hg), tachycardic (heart rate, 122 beats per minute), and in respiratory distress (36 breaths per minute with oxygen saturation of 86% on room air and 98% on facemask). Cardiovascular examination was remarkable for grade 5 of 6, holosystolic murmur along the left sternal border, and the presence of significant bibasilar rales. There were numerous palpable petechial lesions on the skin (Figure 1). After admission to the coronary care unit, the …

Bedside assessment of right atrial pressure in critically ill septic patients using tissue Doppler ultrasonography

PurposeRight atrial pressure (RAP) is considered a surrogate for right ventricular filling pressure or cardiac preload. It is an important parameter for fluid management in patients with septic shock. It is commonly approximated by the central venous pressure (CVP) either invasively using a catheter placed in the superior vena cava or by bedside ultrasound, in which the size and respiratory variations of the inferior vena cava (IVC) are measured from the subcostal view. Doppler imaging of the tricuspid valve from the apical 4-chamber view has been proposed as an alternative approach for the estimation of RAP. The tricuspid E/Ea ratio is measured, where E is the peak velocity of the early diastolic tricuspid inflow and Ea is the peak velocity of the early diastolic relaxation of the lateral tricuspid annulus. We hypothesized that the tricuspid E/Ea ratio may represent an alternative to IVC metrics, using invasive CVP as the criterion standard, for the assessment of RAP in critically ill septic patients. Materials and methodsA convenience sample of 30 septic patients, both mechanically ventilated and non–mechanically ventilated, was enrolled. Using a portable ultrasound system, maximum velocity of tricuspid E and Ea was measured from the apical 4-chamber view; and IVC diameter and degree of collapse were measured from the subcostal view. Decision tree induction was used to determine the performance of each model compared with invasive CVP. ResultsOur results suggest that a tricuspid E/Ea ratio of greater than 4.7 can predict a CVP greater than 10 mm Hg in septic patients with sensitivity greater than 85% and specificity greater than 90%. ConclusionsIn this pilot study, Doppler imaging of the tricuspid valve provided a valuable alternative for noninvasive bedside estimation of RAP in septic patients.

Comparison of Right Versus Left Ventricular Strain Analysis as a Predictor of Outcome in Patients With Systolic Heart Failure Referred for Heart Transplantation

The aim of the present study was to explore the relation between right ventricular (RV) and left ventricular (LV) echocardiographic parameters with clinical outcome in patients with advanced heart failure referred for cardiac transplantation. Ninety-eight consecutive patients with advanced systolic heart failure, referred for cardiac transplant evaluation, were enrolled. All patients were prospectively followed for the development of new outcome events, which included hospitalization for acute heart failure, cardiovascular death, heart transplantation, intra-aortic balloon pump implantation, and ventricular assist device implantation. Conventional transthoracic echocardiography was performed in all subjects. RV longitudinal strain (RVLS) by speckle-tracking echocardiography was assessed by averaging all segments in apical 4-chamber view (global RVLS) and by averaging RV free-wall segments (free-wall RVLS). LV global longitudinal and global circumferential strains were also calculated. Of the 98 subjects at baseline, 46 had 67 new events during a mean follow-up of 1.5 ± 0.9years. Free-wall RVLS, global RVLS, N-terminal fragment of the prohormone brain natriuretic peptide, RV fractional area change, and LV end-diastolic volume were independently predictive of combined outcomes (all p <0.0001). The overall performance for the prediction of cardiovascular events was greatest for free-wall RVLS (area under the curve free-wall RVLS: 0.87; global RVLS: 0.67; RV fractional area change: 0.60; N-terminal fragment of the prohormone brain natriuretic peptide, 0.62; global circumferential strain: 0.55; global longitudinal strain: 0.35; and LV ejection fraction: 0.26). Free-wall RVLS showed the highest adjusted hazards ratio. A graded association between the grade of RV dysfunction and the risk of cardiovascular events was only evident for free-wall RVLS and global RVLS. In conclusion, in patients referred for heart transplantation, RVLS is a stronger predictor of outcome than LV longitudinal strain and other conventional parameters, providing a stronger prognostic stratification.

The normal right ventricle in young people: assessment of volumes and myocardial deformation properties by three-dimensional echocardiography and Speckle tracking

Background: Right ventricular (RV) function plays an important role in determining cardiac symptoms in several diseases. It has been demonstrated that the new imaging modality of three-dimensional echocardiography (3DE) is interchangeable to cardiac magnetic resonance in reproducibility and accuracy. Speckle Tracking is a sensitive tool to quantitatively assess regional deformation properties. Purpose: To obtain normal reference ranges for RV volumes, RV EF, by 3DE (TomTec) and RV deformation properties by Speckle Tracking and intra and inter-observer reproducibility. Methods: 60 subjects, 32 males and 28 females, aged 25±7 yrs, without any cardiovascular disease, were included. By E9GE we measured RV maximum and minimum volumes by tracing RV endocardial borders during enddiastolic (largest RV volume) and end-systolic (smallest RV volume) phases, in apical 4-chamber, short-axis, and coronal views. Volumes were indexed for body surface. By Speckle tracking we measured 2D longitudinal systolic RV Strain (S) and Strain rate (SR) in apical 4-chambers view, at level of RV free wall (basal, medium and apical segments). A reproducibility study was performed to compare the intra and inter-observer variability. Results: We have reported references range in young people for volumes and EF (3D RV end-diastolic:33±11ml/mq; end-systolic volume:16±6ml/mq; 3D RVEF 67±8%). RV systolic 2D S values in young people were for apical segment -24,59±4,8%, for medium -29,69±4,78%, for basal -30,1±5,88% and RV systolic 2D SR were for apical -1,44±0,25 S-1, for medium: -1,78±0,37 S-1, for basal:-2±0,4 S-1. Inter and intraobserver variability coefficients were 8% and 7% for 3D volumes and 8% and 4% for S-SR measurements, respectively. Conclusions: The present study provides normal reference values for RV volumes and RVEF by 3DE and normal longitudinal RV deformation values in young people. 3DE is an alternative imaging modality for quantification of RV volumes and EF, showing improved accuracy and lower interobserver and intraobserver variability compared to 2D echocardiography; it overcomes the limitations due to the complex anatomy of the RV.

GW24-e3081 Evaluation of right ventricular systolic function of patients with pulmonary hypertension by pulse wave tissue Doppler imaging

ObjectivesThe study purpose is to investigate the value of pulse wave tissue Doppler imaging (PW-TDI) in evaluating right ventricular systolic function of patients with pulmonary hypertension.Methods78 patients with pulmonary hypertension...

An unique case of “Atypical Ebstein’s Anomaly” with only isolated displacement of the inferior tricuspid leaflet

A 20-year-old sportive male presented with palpitations. Two-dimensional transthoracic echocardiography showed a severely dilated right atrium and a dislocated lateral tricuspid valve towards the right ventricular apex (Fig. 1a) with grade II tricuspid regurgitation (Fig. 1b). The 3D delayed enhancement study by cardiac MRI confirmed that the inferolateral leaflet of the tricuspid valve was 2.7 cm displaced apically, and septal and anterior leaflets were normally implanted (Fig. 2a and ​andb).b). No intracardiac shunting was found. We conclude that this represents a not previously described form of Ebstein’s anomaly in which the septal and anterior leaflets were not displaced. Fig. 1 a and b. A 2D transthoracic echocardiogram (apical 4-chamber view) showing severe dilatation of the right atrium (RA) and apical displacement of the lateral leaflet (LL) of the tricuspid valve towards the apex (a). There is moderate grade II tricuspid ... Fig. 2 a and b. A cardiac MRI showing the dislocated inferior leaflet and the normally implanted septal and anterior leaflets as demonstrated by 3D delayed enhancement imaging (a and b) In a typical Ebstein's anomaly, the septal and inferior leaflets of the tricuspid valve are displaced apically [1] and the anterior leaflet is excessively large, and abnormally attached to the right ventricular free wall [2]. To the best of our knowledge, this is the first reported case of an isolated displacement of the inferior tricuspid valve leaflet in Ebstein’s anomaly.

Comparison of Micro-bubble Hang-out Time and Cardiac Catheterization in Determining Reversal of Pulmonary Vascular Resistance by Oxygen Challenge Test Among Patients with Shunt Anomalies: The BUBBLE Study

OBJECTIVES: To determine the utility of micro-bubble hang-out time (MHT) in determining reversal of pulmonary vascular resistance (PVR) by oxygen challenge test among patients with shunt anomalies. METHODS: This is a cross-sectional study involving 16 in-patients aged older than 14 years, with an isolated shunt anomaly, a pulmonary artery pressure of greater than 60 mmHg who underwent a hemodynamic study (HS). Agitated saline was injected intravenously before and after an oxygen challenge. MHT in the right sided chambers was measured in seconds using the apical 4-chamber view. Patient then had a HS within 24 hours, determining PVR and reversibility. Non-invasive and invasive parameters were then correlated. RESULTS: Thirteen patients were found to have reversible PVR as determined by HS (pre-oxygen MHT of 76.36 s ± 25.35 and post-oxygen MHT of 37.18 s ± 15.04; p=0.001), and three patients had irreversible PVR (pre-oxygen MHT of 158.37 s ± 120.41 and post-oxygen MHT of 108.82 ± 80.17; p=0.167). A 60-s cut-off for post-oxygen MHT in determining reversibility had a 100% sensitivity, specificity, and positive and negative predictive values (Kappa=1.000). CONCLUSION: A post-oxygen MHT cut-off of 60 s, independent of the pre-oxygen MHT, can be used as an alternative to an HS in labeling patients with isolated shunt anomalies and moderate to severe pulmonary hypertension, into those with reversible (≤ 60 s) and irreversible (&gt; 60 s) PVR. KEYWORDS: Contrast, bubble study, hang-out time, pulmonary vascular resistance, pulmonary hypertension, congenital heart disease, shunts.