Apical Four-chamber View Research Articles

Echocardiographic assessment of right ventricular functions in healthy subjects who migrated from the sea level to a moderate altitude

Objective:The aim of this study was to evaluate right ventricle (RV) functions using echocardiography in healthy subjects who migrated from the sea level to moderate altitude (1890 m).Methods:The prospective observational in this study population consisted of 33 healthy subjects (23 men; mean age 20.4±3.2 years) who migrated from the sea level to a moderate altitude (Erzurum city centre, 1890 m above sea level) for long-term stay. Subjects underwent echocardiographic evaluation within the first 48 h of exposure to the moderate altitude and at the sixth month of arrival. Conventional echocardiographic parameters such as RV sizes and areas, systolic, and diastolic functional indices [fractional area change (FAC), tricuspid flow velocities, myocardial performance index (MPI), and tricuspid annular plane systolic excursion (TAPSE)] were obtained. Systolic (S) and diastolic (E’, A’) velocities were acquired from the apical four-chamber view using tissue Doppler imaging. Kolmogorov–Smirnov test, student’s t-test, Wilcoxon test, and chi-square test were used in this study.Results:There were no significant changes in RV size, FAC, MPI, TAPSE, inferior inspiratory vena cava collapse, tricuspid E velocity, and tricuspid annulus E’ velocity. Compared with the baseline, there was a significant increase in mean pulmonary artery pressure (p=0.001); RV end systolic area (p=0.014); right atrial end diastolic area (p=0.021); tricuspid A velocity (p=0.013); tricuspid annulus S and A’ velocity (p=0.031 and p=0.006, respectively); and RV free wall S, E’, and A’ velocity (p=0.007, p<0.001, and p=0.007 respectively) at the sixth month. Also, there was a significant decrease in tricuspid E/A ratio (1.61±0.3 vs. 1.45±0.2, p=0.038) and tricuspid annulus E’/A’ ratio (1.52±0.5 vs. 1.23±0.4, p=0.002) at the sixth month.Conclusion:Our study revealed that right ventricular diastolic function was altered while the systolic function was preserved in healthy subjects who migrated from the sea level to a moderate altitude. (Anatol J Cardiol 2016; 16: 779-83)

Clinical utility of right ventricular fractional area change in preterm infants

IntroductionRight ventricular fractional area change (RV FAC) is a novel non-invasive quantitative measure of RV function. Reference values of RV FAC and RV end systolic and diastolic areas (RVEDA, RVESA) have recently been established in preterm infants, but their role as marker to assess the efficacy of patient management strategies in the first week of life is largely unknown. The aims of this study were to assess the relationship between RV FAC and gestational age/birthweight, assess the RV FAC on day one of age to predict the later evolution of peri/intraventricular haemorrhage (P/IVH), and assess the influence of a persistent patent ductus arteriosus (PDA) on RV FAC during the first week of age. MethodsPreterm infants <29weeks gestation underwent echocardiography assessments on days 1, 2 and 5–7. RVEDA and RVESA were traced in the RV-focused apical four-chamber view, and RV FAC was calculated using the formula [(RVEDA−RVESA)÷(RVEDA)]×100. PDA treatment was not carried out during the study period. A cranial ultrasound was carried out on all infants on Days 5–7 of age. P/IVH was defined as IVH grades II to IV. ResultsOne hundred and one infants with a mean gestation of 26.5 (1.4) weeks and a birthweight of 983 (240) grams were enrolled in the study. There was no relationship between RV FAC and birthweight (r=−0.02, p=0.86) but there was a negative correlation between RV FAC and echo-measured SVR (r=−0.57, p<0.001). On Day 1, RV FAC was lower in infants who developed P/IVH (24% [18–34] vs. 31% [25–40], p=0.04). On Days 5–7 infants with a PDA had a lower RV FAC compared with those without [42 (7) vs. 49 (9) %, p<0.001]. ConclusionRV FAC may be a useful addition to the haemodynamic assessment of preterm infants during the first week of age.

Unsuspected large left ventricular pseudoaneurysm: rapid bedside diagnosis by contrast-enhanced echocardiography: Figure 1:

An asymptomatic 72-year-old man with cardiomegaly was referred to our centre for assessment. His medical history comprised metastatic colonic cancer and granulomatosis with polyangiitis. Transthoracic echocardiography was performed. In the apical four-chamber view, a large cavity was identified adjacent to the apex, measuring 45 × 54 mm (Fig. 1A and Supplementary Video 1). All apical segments of the left ventricle were thin and akinetic. On colour Doppler, bidirectional blood flow due to swirling of blood was observed within the cavity (Fig. 1B and Supplementary Video 2). Contrast-enhanced echocardiography established the site of rupture within the thinned apical wall of the left ventricle, measuring 15 mm in width, communicating freely with a large, thrombus-free pseudoaneurysm (Fig. 1C and Supplementary Video 3). Cardiovascular magnetic resonance imaging confirmed the finding of an apical pseudoaneurysm (Fig. 1D and Supplementary Video 4). Late gadolinium enhancement was limited to the apical segments in a transmural distribution. The remaining segments of the left ventricle were functioning and viable with no evidence of inducible ischaemia. Coronary angiography demonstrated unobstructed arteries. Figure 1: (A) Transthoracic echocardiogram; four-chamber view. (B) Colour Doppler showing bidirectional flow of blood within the left ventricular pseudoaneurysm. (C) Contrast-enhanced transthoracic echocardiogram, zoomed on the left ventricular pseudoaneurysm. ... In this case, the likely primary event was an unrecognized myocardial infarction, followed by ventricular wall rupture contained within pericardial tissue. Possible mechanisms for the myocardial infarction include acute coronary artery occlusion with spontaneous recanalization, coronary thromboembolism and coronary vasculitis. This patient's case was discussed in a multidisciplinary team meeting. The consensus view was that the risk of rupture of the pseudoaneurysm was small. Furthermore, the patient's survival was estimated to be 1 year due to his metastatic colonic cancer. Consequently, medical treatment was advised. The natural history of left ventricular pseudoaneurysms is not known. If left untreated, left ventricular pseudoaneurysms predispose to ventricular rupture, thromboembolism, compression of local structures and arrhythmia. Most pseudoaneurysms require surgical intervention [1] or percutaneous closure [2]. When a left ventricular pseudoaneurysm is chronic, there are limited outcome data to guide the need for surveillance and timing of intervention. This case illustrates the value of contrast-enhanced echocardiography as a low cost adjunct to complex imaging modalities, to rapidly distinguish left ventricular pseudoaneurysms from other cardiac pathology. No ethical approval is required. The patient provided written consent. R.S. is nominated as the guarantor of this work.

Longitudinal annular displacement by M-mode (MAPSE and TAPSE) in twin-to-twin transfusion syndrome before and after laser surgery.

To evaluate mitral and tricuspid annular plane systolic excursion (MAPSE and TAPSE) in fetuses with twin-to-twin transfusion syndrome (TTTS) before and after laser therapy. A prospective study in 24 fetal pairs with TTTS evaluated 24 h before and within 48 h after fetoscopy and 13 gestational age-matched normal monochorionic fetal pairs. MAPSE and TAPSE were measured in an apical or basal four-chamber view by placing the M-mode cursor at the lateral valve ring. Mean preoperative MAPSE (controls 3.6 ± 1.3 mm vs. donors 2.7 ± 0.8 mm vs. recipients 2.8 mm ± 0.9; P < 0.001) and TAPSE (controls 4.4 ± 1.5 mm vs. donors 3.3 ± 1 mm vs. recipients 3.6 ± 1.1 mm; P < 0.001) values were significantly reduced in both TTTS fetuses. When subdividing according to TTTS stages, changes were significant in both stage I-II and III-IV subgroups, although differences were more pronounced in the latter. All observations remained unchanged 48 h post-fetoscopy. Both recipient and donor fetuses had decreased global longitudinal motion, even in early TTTS stages.

Double row of overlapping sutures for downsizing annuloplasty decreases the risk of residual regurgitation in ischaemic mitral valve repair.

The aim of this study was to evaluate a novel insertion technique of the prosthetic ring that would further magnify the degree of annulus narrowing, thereby reducing the potential for a residual leak in ischaemic mitral valve repair. Thirty-six patients with ischaemic mitral regurgitation (MR) were randomly assigned into two groups. In 18 patients, the prosthetic ring was inserted in the conventional manner with a single row of sutures (control group). In the remaining 18 patients, the ring was attached using a double row of sutures tied both on the inner and on the outer part of the sewing cuff. Both groups had similar preoperative clinical and echocardiographic characteristics with severe leaflet tethering: mean tenting area >2.5 cm(2), mean anterior leaflet angle >25° and posterior leaflet angle >45°. The mean prosthetic ring sizes inserted in both groups were identical (mean: 27.3 mm). At 12 months, there was no clinical event except for 1 rehospitalization in the control group. The mean mitral regurgitation grade was higher in the control group than in the group with the double row of sutures at 1.6 ± 0.9 vs 0.7 ± 0.3 (P = 0.0003). Annulus diameter reduction was less pronounced in the control group when compared with the group with the double row of sutures, both in the parasternal long-axis: 29.3 ± 3 vs 26.3 ± 3 mm (P = 0.0003) and in apical four-chamber views: 31 ± 3 vs 28 ± 2 mm (P = 0.003). Leaflet tethering indices were greater in the control group than in the group with the double row of sutures: tenting area: 1.42 ± 0.3 vs 1.1 ± 0.5 cm(2) (P = 0.002), anterior leaflet angle: 33 ± 3° vs 28 ± 5° (P = 0.0009) and posterior leaflet angle: 110 ± 13° vs 80 ± 11° (P = 0.0001). Left ventricular function parameters were not statistically different among the two groups. A double row of overlapping sutures for attaching the prosthetic ring in downsizing annuloplasty is more efficient in narrowing the mitral annulus than the conventional technique in ischaemic mitral repair. Even in high-risk patients whose leaflets were severely tethered on echocardiography, it almost eliminated the risk of MR recurrence in this study.

Value of annular plane systolic excursion difference in evaluation of heart systolic function of normal fetuses in the second and late trimester with echocardiography

Objective To obtain the annular plane systolic excursion difference (APSED) of fetuses in second and late trimester by free angle M-mode(FAM) and tissue motion of annular displacement(TMAD) in order to assess the fetal ventricular function. Methods The mitral annular plane systolic excursion(MAPSE) and tricuspid annular plane systolic excursion(TAPSE) of four hundred and fifty five normal fetuses from 20 to 41 weeks were measured by FAM echocardiography, and the difference between them were calculated. Early diastolic velocities (Em) of the mitral annular and early diastolic velocities (Em') of the tricuspid annular were estimated by pulsed-wave tissue Doppler imaging(TDI), meanwhile systolic velocities (Sm) of the mitral annular and systolic velocities (Sm') of the tricuspid annular were also estimated by TDI. Fifty normal fetuses in the second and late trimester were choosed randomly, two-dimension imaging was obtained at the apical four-chamber view, then mitral annular plane and tricuspid annular plane displacement curve were acquired at the same time by using off-line QLab 8.1 software, and the differences in the peak time between them were compared. The trace of annular displacement were recorded by color tissue tracking technology. Results There was a significant difference between FAM-TAPSE and FAM-MAPSE in different gestational weeks (P 0.05). Conclusions The APSED existed in the second and late trimester continually. It was considering associated with fetal ventricular torsion. As the growth of gestational weeks, the increase of APSED reflected the enhanced reserve capacity of the fetal ventricular torsion. APSED can reflect the longitudinal motion and torsion movement of fetal ventricle quantitatively, and can be used as a new index to assess the fetal cardiac function. Key words: Echocardiography; Fetal heart; Ventricular function; Tissue motion of annular displacement; Annular plane systolic excursion difference

Strain echocardiography identifies impaired longitudinal systolic function in patients with septic shock and preserved ejection fraction.

BackgroundMyocardial dysfunction is recognized in sepsis. We hypothesized that mechanical left (LV) and right (RV) ventricular function analysed using 2-dimensional speckle-tracking echocardiography in a cohort of early severe sepsis or septic shock patients, would be different to that of a group of critically ill, non-septic patients.MethodsCritically ill adult patients with early, severe sepsis/septic shock (n = 48) and major trauma patients with no sepsis (n = 24) were included retrospectively, as well as healthy controls (n = 16). Standard echocardiographic examinations, including right (RV) left (LV) volumes and mitral, aortic and pulmonary vein Doppler flow profiles, were retrospectively identified and the studies were then reanalysed for assessment of myocardial strain using speckle-tracking echocardiography. Endocardial tracing of the LV was performed in apical four-chamber (4-Ch), two-chamber (2-Ch), apical long-axis (3-Ch) and apical views of RV determining the longitudinal LV and RV free wall strain in each subject.ResultsIn septic patients, heart rate was significantly higher (p = 0.009) and systolic (p < 0.001) and mean arterial pressures (p < 0.001), as well as systemic vascular resistance (p < 0.001) were significantly lower when compared to the non-septic trauma group. Ninety-three per cent of the septic patients and 50 % of the trauma patients were treated with norepinephrine (p < 0.001). LV ejection fraction (LVEF) was lower in the septic patients (p = 0.019). In septic patients with preserved LVEF (>50 %, n = 34), seventeen patients (50 %) had a depressed LV global longitudinal function, defined as a LV global strain > −15 %, compared to two patients (8.7 %) in the non-septic group (p = 0.0014). In septic patients with preserved LVEF, LV global and RV free wall strain were 14 % (p = 0.014) and 17 % lower (p = 0.008), respectively, compared to the non-septic group with preserved LVEF. There were no significant differences between groups with respect to LV end-diastolic or end-systolic volumes, stroke volume, or cardiac output. There were no signs of diastolic dysfunction from the mitral or pulmonary vein Doppler profiles in the septic patients.ConclusionsLV and RV systolic function is impaired in critically ill patients with early septic shock and preserved LVEF, as detected by Speckle-tracking 2D echocardiography. Strain imaging may be useful in the early detection of myocardial dysfunction in sepsis.Electronic supplementary materialThe online version of this article (doi:10.1186/s12947-015-0025-4) contains supplementary material, which is available to authorized users.

Assessment of subclinical left ventricular dysfunction in patients with psoriasis by speckle tracking echocardiography: A Speckle Tracking Study.

Psoriasis is a systemic inflammatory disease and is reportedly associated with adverse cardiovascular risks. Left ventricular (LV) function has not been studied comprehensively in psoriasis. This study was conducted to study LV mechanics in patients with psoriasis by speckle tracking echocardiography. The study population consisted of 40 patients with psoriasis and 35 age- and sex-matched control subjects. Two-dimensional echocardiography images were obtained from LV apical four-chamber (4C), long axis (LAX), and two-chamber (2C) views. Peak longitudinal strain and strain rate were obtained from 4C, LAX, and 2C views. Global strain and strain rate were calculated by averaging data for the three apical views. Patients with psoriasis had significantly lower mean±standard deviation (SD) 4C (17.1±1.7 vs. 19.2±2.3; P<0.01), LAX (16.6±1.5 vs. 19.5±2.3; P<0.01), and 2C (16.5±1.5 vs. 19.4±2.2; P<0.01) peak longitudinal strain values compared with the control group. Moreover, mean±SD LV global strain (16.6±1.5 vs. 19.9±2.1; P<0.01) and strain rate (1.39±0.30 vs. 1.51±0.20; P<0.01) values were found to be significantly lower in the psoriasis group. In a multiple regression model, global strain was independently associated with high-sensitivity C-reactive protein (β=0.29, P=0.04), duration of disease (β=0.35, P<0.01), ejection fraction (EF) (β=0.38, P=0.01), and the ratio of early diastolic mitral inflow velocity to early diastolic annular velocity (E/E' ratio) (β=0.34, P=0.02). Also, in a multiple regression model, global strain rate was independently associated with duration of disease (β=0.36, P<0.01), EF (β=0.32, P=0.01), and E/E' ratio (β=0.35, P<0.01). Using 2-D strain imaging, we have demonstrated that patients with psoriasis have lower LV functions.

McConnell's Sign Is Not Specific for Pulmonary Embolism: Case Report and Review of the Literature

BackgroundMcConnell's sign (right ventricular [RV] free wall hypokinesis with apical sparing on echocardiography) is often described as very specific for the diagnosis of pulmonary embolism (PE). We present the case of a patient who, despite manifesting a classic McConnell's sign, was not found to have a PE. Case ReportA 58-year-old woman presented to the emergency department with a cough, dyspnea, and leg swelling. A bedside focused cardiac ultrasound revealed hypokinesis of the RV free wall, with apical sparing, in the apical four-chamber view. A computed tomography angiogram for PE was negative. Ultrasounds of both lower extremities were negative for deep venous thrombosis, and a D-dimer was only marginally elevated. The patient was ultimately diagnosed with pulmonary hypertension due to chronic obstructive pulmonary disease and systemic lupus erythematosus. Why Should an Emergency Physician Be Aware of This?Emergency physicians should be aware that McConnell's sign is not completely specific for acute right heart strain from PE.

Evaluation of left ventricular systolic function in different layers myocardium in patients with hypertrophic cardiomyopathy by two-dimensional speckle tracking echocardiography

Objective To assess the systolic function in left ventricular subendocardial myocardium, midmyocardium and subepicardial myocardium in patients with hypertrophic cardiomyopathy (HCM) by two-dimensional speckle tracking echocardiography. Methods A total of 32 patients with HCM and 32 healthy adults were included in the study. All standard measurements were obtained from the left ventricular short-axis views at the levels of mitral annulus, papillary muscle and apex, and apical four-chamber, two-chamber, and long-axis views. Two-dimensional speckle tracking imaging was employed. The global peak systolic radial strain, peak systolic longitudinal strain and circumferential strain of each layer of the left ventricle were measured. Results In patients with HCM and the control group, the peak systolic longitudinal strain and circumferential strain reduced from subendocardial myocardium to subepicardial myocardium. The global peak systolic radial strain in patients with HCM was significant lower than that in the control group. And in patients with HCM, peak systolic longitudinal strain in subendocardial myocardium, midmyocardium and subepicardial myocardium was significant lower than those in the control group. Conclusions Peak systolic longitudinal strain and circumferential strain are reduced from subendocardial myocardium to subepicardial myocardium.Myocardial systolic function is impaired in patients with HCM. In patients with HCM, longitudinal strain of each layer is lower, but circumferential strain is mainly reduced in midmyocardium and subepicardial myocardium compared with that in the control group. Key words: Echocardiography; Cardiomyopathy, hypertrophic; Ventricular function, left; Two-dimensional speckle tracking imaging

Left ventricular longitudinal rotation changes in primary hypertension patients with normal left ventricular ejection fraction detected by two-dimensional speckle tracking imaging.

In order to assess the left ventricular (LV) longitudinal rotation (LR) in primary hypertension (PH) patients with a normal LV ejection fraction. Conventional echocardiography was performed in 61 healthy subjects and 64 PH patients. The apical four-chamber views in these patients were acquired by GE-Vivid7 or E9, then the peak radial strain in the systolic period and the strain rate in systole, in early and late diastolic periods, were measured. Segmental LR and global LR were assessed by using two-dimensional speckle tracking imaging (2D-STI). The peak radial strain rate in the early diastolic period in PH patients was significantly lower than that in healthy subjects. The rotational degrees of the middle and base lateral, the apex and the middle septum walls in PH patients were significantly different from those of the healthy subjects. The healthy subjects had prominent counter-clockwise LR (0.29°±2.86°) and the PH patients had prominent clockwise LR (-2.13°±2.93°) in non-LV wall hypertrophy and (-2.43°±2.66°) in LV wall hypertrophy. The time delay between the LV lateral wall and the septum wall in PH patients correlated to the peak LR. We concluded that 2D-STI can assess the time delay between the LV lateral wall and the septum wall to the peak LR and clockwise LR in patients with PH, and prove that PH patients have a clockwise LR. By this, we conclude that in PH patients, the LV early systolic function have changed.

Right Ventricular Function in Preterm and Term Neonates: Reference Values for Right Ventricle Areas and Fractional Area of Change

Right ventricular (RV) fractional area of change (FAC) is a quantitative two-dimensional echocardiographic measurement of RV function. RV FAC expresses the percentage change in the RV chamber area between end-diastole (RV end-diastolic area [RVEDA]) to end-systole (RV end-systolic area [RVESA]). The objectives of this study were to determine the maturational (age- and weight-related) changes in RV FAC and RV areas and to establish reference values in healthy preterm and term neonates. A prospective longitudinal study was conducted in 115 preterm infants (23-28weeks' gestational age at birth, 500-1,500g). RV FAC was measured at 24hours of age, 72hours of age, and 32 and 36weeks' postmenstrual age (PMA). The maturational patterns of RVEDA, RVESA, and RV FAC were compared with those in 60 healthy full-term infants in a cross-sectional study (≥37weeks, 3.5 ± 1kg), who underwent echocardiography at birth (n=25) and 1 month of age (n=35). RVEDA and RVESA were traced in the RV-focused apical four-chamber view, and FAC was calculated using the formula 100 × [(RVEDA - RVESA)/RVEDA)]. Premature infants who developed chronic lung disease or had clinically and hemodynamically significant patent ductus arteriosus were excluded (n=55) from the reference values. Intra- and interobserver reproducibility analysis was performed. RV FAC ranged from 26% at birth to 35% by 36weeks' PMA in preterm infants (n=60) and increased almost 2 times faster in the first month of age compared with healthy term infants (n=60). Similarly, RVEDA and RVESA increased throughout maturation in both term and preterm infants. RV FAC and RV areas were correlated with weight (r=0.81, P<.001) but were independent of gestational age at birth (r=0.3, P=.45). RVEDA and RVESA were correlated with PMA in weeks (r=0.81, P<.001). RV FAC trended lower in preterm infants with bronchopulmonary dysplasia (P=.04) but was not correlated with size of patent ductus arteriosus (P=.56). There was no difference in RV FAC based on gender or need for mechanical ventilation. This study establishes reference values of RV areas (RVEDA and RVESA) and RV FAC in healthy term and preterm infants and tracks their maturational changes during postnatal development. These measures increase from birth to 36weeks' PMA, and this is reflective of the postnatal cardiac growth as a contributor to the maturation of cardiac function These measures are also linearly associated with increasing weight throughout maturation. This study suggests that two-dimensional RV FAC can be used as a complementary modality to assess global RV systolic function in neonates and facilitates its incorporation into clinical pediatric and neonatal guidelines.

Right ventricular marantic endocarditis

A 68-year-old female presented with chest pain and breathlessness. She had breast carcinoma treated 17 years ago, with further surgical excision for recurrence 7 years ago. Computerised tomography (CT) demonstrated bi-lateral pulmonary embolism, with extensive lymphadenopathy and lung metastases. She was treated with therapeutic heparin. Echocardiography revealed a right ventricular mass attached to the tricuspid valve chordae (Fig. 1; Videos 1 and 2), which could be thrombus, marantic or infective vegetation. Blood cultures were negative. Lymph node biopsy showed malignant cells, likely of breast origin. Despite therapeutic anti-coagulation, echocardiogram 3 weeks after initial presentation demonstrated enlargement of the original mass and an additional mass (Fig. 1; Videos 3 and 4), implying that these were most probably marantic. We retrospectively reviewed the CT performed at first presentation, which also demonstrated the original right ventricular mass (Fig. 1). She died from recurrent embolic cerebrovascular events, confirmed on MRI, within a month from initial presentation. In advanced stages of malignancy, marantic endocarditis or non-bacterial thrombotic endocarditis can develop in hypercoagulable states. It has a rapidly progressive course, with embolisation of vegetations to other organs. The sterile vegetations consist of fibrin and platelets (1, 2). Patients should be anti-coagulated. In terminal cases, surgery rarely alters the final outcome (2, 3). Figure 1 (A and B) Right ventricular mass (arrowed) attached to the tricuspid valve chordae apparatus on echocardiography, in apical four-chamber view, and modified parasternal right ventricular inflow view respectively; (C and D) repeat echocardiogram demonstrating ... Video 1 The initial right ventricular mass attached to the tricuspid valve chordae apparatus on echocardiography, in modified parasternal right ventricular inflow view. Download Video 1 via http://dx.doi.org/10.1530/ERP-14-0066-v1 Download Video 1 Video 2 The initial right ventricular mass attached to the tricuspid valve chordae apparatus on echocardiography, in apical four-chamber view. Download Video 2 via http://dx.doi.org/10.1530/ERP-14-0066-v2 Download Video 2 Video 3 Repeat echocardiogram demonstrating enlargement of the original mass and an additional mass, in modified parasternal right ventricular inflow view. Download Video 3 via http://dx.doi.org/10.1530/ERP-14-0066-v3 Download Video 3 Video 4 Repeat echocardiogram demonstrating enlargement of the original mass and an additional mass, in apical four-chamber view. Download Video 4 via http://dx.doi.org/10.1530/ERP-14-0066-v4 Download Video 4

Echocardiographic Characteristics of Annulo-Leaflet Mitral Ring

Annulo-leaflet mitral ring (ALMR) is a rare congenital cardiac anomaly caused by fibrous tissue on the atrial surface of the mitral valve, which can progress to cause severe stenosis. Because little information is available on the detailed echocardiographic features of the anomaly and their associations with surgical resection, this study was undertaken to address these questions. A retrospective single-center study of clinical and echocardiographic data from patients with ALMR from 2004 through 2012 was conducted. Data were analyzed for associations with surgical resection. The median age at diagnosis of the 57 study patients was 1.8years, and 63% were male. Isolated ALMR was found in six patients (11%). The remaining 51 patients (89%) had associated lesions: additional mitral valve abnormalities in 35 (61%), coarctation in 11 (19%), and subaortic stenosis in 15 (26%). ALMR was best visualized in the apical four-chamber view, and the lesion was indistinct from the parasternal long-axis view in 25% of patients. Seven patterns of ALMR were identified, differentiated by leaflet involvement (anterior, posterior, or both) and location (annular vs intraleaflet). Compared with other patterns, intraleaflet morphology had a higher mean mitral stenosis gradient than in patients without (8.4 vs 5.8mm Hg, P=.01). Among the 57 patients, 32 (56%) underwent ALMR resection, at a median age of 1.5years. Younger age at echocardiographic diagnosis (P=.02) and short chordae (P=.03) were associated with resection. The morphology of ALMR as evaluated by echocardiography is heterogeneous and can be classified on the basis of lesion location and leaflet involvement. Intraleaflet morphology is associated with significant mitral stenosis; younger age at diagnosis and short chordae are associated with ALMR resection.

Feasibility and Diagnostic Potential of Pulmonary Transit Time Measurement by Contrast Echocardiography: A Pilot Study.

Pulmonary transit time (PTT; the time for ultrasound contrast to travel from the right ventricle [RV] to the left atrium) may provide a single metric that reports on cardiopulmonary function while overcoming some of the challenges of standard echocardiographic measures. We conducted a pilot study to test the feasibility and reproducibility of echocardiographically derived PTT and to determine its association with established measures of cardiopulmonary function. A total of 39 patients receiving clinically indicated ultrasound contrast were prospectively enrolled. PTT was measured in the apical four-chamber view using commercially available software. Reproducibility and inter-observer agreement were assessed in 9 patients. PTT was correlated with established measures of left ventricular systolic and diastolic function, RV function, and pulmonary vascular status. PTT could be measured in 89% (33/37) of patients without a contraindication to ultrasound contrast; all measurements from the last 20 patients were interpretable and obtained independently by a sonographer. Reproducibility and inter-observer agreement were excellent. PTT correlated well with standard echocardiographic indicators of cardiac status. A PTT >4.5 seconds accurately identified all but 1 patient with cardiopulmonary dysfunction. This pilot study demonstrates that measurement of PTT using ultrasound contrast is highly reproducible, accurately reflects global cardiopulmonary function across a range of cardiopulmonary disease, and can be readily obtained by an independent sonographer. Further studies are needed to determine whether PTT has incremental value in diagnosis and prognosis compared to conventional echocardiographic parameters.

Difficulties encountered by physicians in interpreting focused echocardiography using a pocket ultrasound machine in prehospital emergencies

Pocket ultrasound devices (PUDs) increase the scope of transthoracic echocardiography. We assessed the ability of emergency physicians (EPs) to obtain and interpret views using PUDs in prehospital emergencies. Nine EPs underwent a 2-day training program focused on acquisition of four views and on evaluation of left ventricular function, right ventricular size, the inferior vena cava, and detection of pericardial effusion. Then, EPs used a PUD to perform transthoracic echocardiography in patients with shock or acute respiratory failure. The quality and interpretation of views were graded by an expert as not obtained/inadequate, adequate, or optimal. Agreement between the expert and the physicians was evaluated using Cohen's κ test. One hundred consecutive exams were evaluated in patients with shock or acute respiratory failure. Parasternal long-axis and short-axis views, and a subcostal view were not obtained or inadequate in 56, 54, and 54 patients, respectively. An apical four-chamber view was not obtained or inadequate in 33 patients. One, two, or three views were graded as adequate or optimal in 86, 65, and 35 patients. Agreement between physicians and experts for left ventricular systolic function, right ventricular size, and pericardial effusion was weak [κ 0.37 (0.17; 0.59), 0.27 (0.023; 0.53), and 0.33 (-0.008; 0.67)]. Agreement for inferior vena cava evaluation was very weak [0.13 (-0.17; 0.43)]. After a very short training program, echocardiography using a PUD in prehospital emergencies was feasible in half of patients. Acquisition of technical skills is reasonable, but accurate evaluation of cardiac function may require more extensive training.

Impairment of Left Ventricular Longitudinal Contraction is Associated with Serum Brain Natriuretic Peptide Concentration in Patients with Acute-Phase Kawasaki Disease.

It is well known that brain natriuretic peptide (BNP) is elevated in the acute phase of Kawasaki disease (KD). We hypothesized that mitral annular plane systolic excursion (MAPSE) could identify LV dysfunction in the acute phase of KD. Fifty patients with KD were enrolled in this study. BNP sampling and an echocardiographic study were performed just before and after intravenous immunoglobulin administration. MAPSE was measured in M-mode in the apical four-chamber view. The %MAPSE was calculated as the MAPSE measured in the acute phase divided by that measured in the convalescent phase. We compared the acute and the convalescent phases of KD. The values of the MAPSE were significantly reduced (45 out of 50 patients) during the acute phase and immediately recovered in the convalescent phase (10.0 ± 1.9 vs. 12.7 ± 1.9 mm, P < 0.0001). Of the parameters tested, %MAPSE was the only echocardiographic parameter that was associated with Log-BNP. Additionally, %MAPSE had a significant negative correlation with Log-BNP (r = -0.45, P < 0.0039). Longitudinal LV contraction is impaired in the acute phase of KD, but it immediately recovers in the convalescent phase. Measuring the longitudinal LV contractility should be essential for evaluating LV function in the acute phase of KD, and MAPSE is useful for this evaluation.

Right and Left Atrial Dissimilarities in Normal Subjects Explored by Speckle Tracking Echocardiography.

Atrial function is an important contributor of ventricular function and has a prognostic role in various cardiovascular diseases. We tested the hypothesis that right and left atrial (RA & LA) function may not be equal despite their accommodating identical cardiac output. Two-dimensional (2D) speckle tracking echocardiography was acquired from the apical four-chamber view in 100 normal subjects. Both RA/LA subendocardial borders were traced to obtain atrial volumes, strain (ε) and strain rate (SR). Reservoir, conduit, and booster pump functions were evaluated. Consequently, εNeg (corresponding to pump function) and εPos (corresponding to conduit function) were gauged. The SR parameters (SRLateNeg, SRPos, and SREarlyNeg), corresponding respectively to atrial systole, inception of ventricular systole, and inception of ventricular diastole, were measured. Mean age was 39 ± 15 years with 50 men (50%). Volumetric indices revealed that reservoir (Filling Volume = 35.1 ± 10.4 mL for LA vs. 27.47 ± 11.93 mL for RA, expansion index = 52.18 ± 16.89% for LA vs. 45.03 ± 16.49% for RA and diastolic emptying index = 52.85 ± 16.85 for LA vs. 45.62 ± 16.5 for RA, P < 0.001) and conduit (passive emptying (%) of total emptying = 34.49 ± 10.4 for LA vs. 26.82 ± 11.98 for RA and passive emptying index = 52.63 ± 16.86 for LA vs. 45.39 ± 16.5 for RA, P < 0.001) functions were significantly higher in the LA compared to the RA. Nevertheless, deformation indices demonstrated an opposite pattern (SRpos = 1.88 ± 0.74 for RA vs. 1.56 ± 0.54 for LA, P = 0.03 and εPos = 59.56 ± 30.63 for RA vs. 45.94 ± 16.67 for LA, P < 0.001). Reservoir, conduit, and booster pump functions showed no statistical significance among both genders. Evaluation of global and regional RA/LA function by speckle tracking echocardiography is feasible. The current report provides insights regarding dissimilarities between both atria in healthy individuals. The significance of these findings and their potential application will warrant further work.

Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging.

The rapid technological developments of the past decade and the changes in echocardiographic practice brought about by these developments have resulted in the need for updated recommendations to the previously published guidelines for cardiac chamber quantification, which was the goal of the joint writing group assembled by the American Society of Echocardiography and the European Association of Cardiovascular Imaging. This document provides updated normal values for all four cardiac chambers, including three-dimensional echocardiography and myocardial deformation, when possible, on the basis of considerably larger numbers of normal subjects, compiled from multiple databases. In addition, this document attempts to eliminate several minor discrepancies that existed between previously published guidelines.

Assessment of left atrial function in patients with systolic heart failure: strain imaging study

Objectives The aim of this work was to assess the left atrial function by speckle tracking in patients with systolic heart failure. Background Heart failure is a clinical syndrome characterized by impaired structure and/or function of the heart, leading to dyspnea and fatigue at rest or with exertion. The pathophysiology of heart failure is complex and there is no single lesion. The left atrial function contributes toward left ventricular filling by means of its three components: a reservoir component; a passive conduit component; and a pump component, with active contraction. Changes in atrial function during the different phases of the cardiac cycle can be assessed noninvasively by the new 2D strain, derived from speckle tracking, that allows us to identify these three components of atrial function. Materials and methods This study included 50 randomly selected individuals: 30 with systolic heart failure and ejection fraction (EF) less than 50% (patient group) and 20 normal individuals (control group). Left ventricle (LV) volumes were measured. Left atrium (LA) volumes were measured at the end of systole, LA maximum volume (Max AV), at the end of diastole, LA minimum volume (Min AV), and preceding atrial contraction (VPre-A). LA total emptying volume (LAEV), LA total emptying fraction(LAEF), LA passive emptying volume (LApEV), LA passive emptying fraction (LApEF), LA active emptying volume (LAAEV), and LA active emptying fraction (LAAEF) were calculated in both apical four-chamber and apical two-chamber views. Peak atrial longitudinal strain, peak atrial contraction strain, and LA strain at the end of LA contraction (Post-A) were measured. The LA contraction systolic index was calculated. LV global strain was measured in apical four-chamber, two-chamber and three-chamber views. LV strain rate was determined, and the LV peak systolic, early diastolic, and late diastolic strain rate were measured. Results Patients with systolic heart failure showed a significant increase in LV volumes and LA volumes (Max AV, Min AV, and VPre-A volumes) compared with the control group. A significant decrease in LA peak atrial longitudinal strain, peak atrial contraction strain, Post-A, and LA contraction systolic index was observed in patients with systolic heart failure ( P Conclusion Increased LA volumes and decreased LA function were measured by strain and volumetric parameters in patients with systolic heart failure compared with controls.