Continuous Wave Doppler Echocardiography Research Articles

Echocardiographic estimation of right ventricular diastolic stiffness based on pulmonary regurgitant velocity waveform analysis in precapillary pulmonary hypertension.

Right ventricular (RV) diastolic stiffness is an independent predictor of survival and is strongly associated with disease severity in patients with precapillary pulmonary hypertension (PH). Therefore, a fully validated echocardiographic method for assessing RV diastolic stiffness needs to be established. This study aimed to compare echocardiography-derived RV diastolic stiffness and invasively measured pressure-volume loop-derived RV diastolic stiffness in patients with precapillary PH. We studied 50 consecutive patients with suspected or confirmed precapillary PH who underwent cardiac catheterization, magnetic resonance imaging, and echocardiography within a 1-week interval. Single-beat RV pressure-volume analysis was performed to determine the gold standard for RV diastolic stiffness. Elevated RV end-diastolic pressure (RVEDP) was defined as RVEDP ≥ 8 mmHg. Using continuous-wave Doppler and M-mode echocardiography, an echocardiographic index of RV diastolic stiffness was calculated as the ratio of the atrial-systolic descent of the pulmonary artery-RV pressure gradient derived from pulmonary regurgitant velocity (PRPGDAC) to the tricuspid annular plane movement during atrial contraction (TAPMAC). PRPGDAC/TAPMAC showed significant correlation with β (r = 0.54, p < 0.001) and RVEDP (r = 0.61, p < 0.001). A cut-off value of 0.74 mmHg/mm for PRPGDAC/TAPMAC showed 83% sensitivity and 93% specificity for identifying elevated RVEDP. Multivariate analyses indicated that PRPGDAC/TAPMAC was independently associated with disease severity in patients with precapillary PH, including substantial PH symptoms, stroke volume index, right atrial size, and pressure. PRPGDAC/TAPMAC, based on pulmonary regurgitation velocity waveform analysis, is useful for the noninvasive assessment of RV diastolic stiffness and is associated with prognostic risk factors in precapillary PH.

Assessment of descending aortic blood flow velocities with continuous wave Doppler echocardiography among healthy Children in South East Nigeria

Background The descending aorta velocity is important predictor of aortic disease in children and can be very helpful in some clinical and surgical decision making.Aim The purpose of this study is to assess the normative values of descending aorta velocity among children from South-East Nigeria. It also aimed to assess the correlation between age, body surface area and mean velocity across the descending aorta. Methods This is a cross-sectional study where the descending aorta velocity of one hundred and eleven children were enrolled consecutively using digitized two-dimensional and Doppler echocardiography.ResultsA total of 111 children had echocardiography to study their cardiac structures and compute their mean scores of their descending aorta velocity. The mean velocity across the descending aorta was 1.3±0.2m/s with maximum and minimum velocities of 2.06 and 0.84cm respectively. The mean descending aorta velocity in males (1.37±0.24 m/s) was significantly higher than that in females (1.24±0.18); (Student T test 3.09, p = 0.03). There was no correlation between age and mean velocity across the descending aorta (Pearson correlation coefficient; -0.03, p = 0.7) nor between body surface area and descending aorta velocity (correlation coefficient 0.01, p= 0.8). Conclusions The presented normalized values of the descending aorta velocity using a digitized two-dimensional and Doppler echocardiography among healthy children will serve as a reference values for further studies and can be applied for clinical and surgical use in children with various cardiac anomalies.

Cardiovascular Hemodynamic Response to Peak Exercise in Individuals with Multiple Sclerosis

Multiple sclerosis (MS) is a chronic, progressive neurological condition that results in physical disability brought about, in part, by decreased aerobic capacity. Physical disability and aerobic deconditioning may increase risks of cardiovascular morbidity and mortality. The reduction in aerobic capacity may be associated with low maximal heart rate and/or low cardiac output. Yet it is unclear if the cardiovascular hemodynamic response to peak exercise differs between individuals with and without MS who have similar aerobic capacities. Purpose: To compare the cardiovascular hemodynamic response to peak exercise between individuals with and without MS, with similar aerobic capacities. We hypothesized individuals with similar aerobic capacities would also exhibit similar hemodynamic responses, regardless of disease condition. Methods: Individuals with MS (n=14 (2 males), 38 ± 8 yrs, 24.6 ± 4.5 kg/m 2 ) and without MS (n=14 (1 male), 33 ± 9 yrs, 28.8 ± 13.8 kg/m 2 ) underwent maximal incremental cycle exercise test to assess maximal aerobic capacity (VO 2 peak). Heart rate (HR) was measured continuously via Polar Heart Rate Monitor. Ascending aortic blood flow velocity images (VTI) via continuous wave Doppler echocardiography, and brachial blood pressure (BP) via brachial sphygmomanometry were obtained every other minute of the exercise test. Stroke volume (SV) was calculated from VTI and the area of the aorta, cardiac output (Q) was calculated as SV × HR, and Mean arterial pressure (MAP) was calculated from BP. Maximal arteriovenous oxygen difference (avO2diff) was calculated as VO 2 peak ⁄ Q. Results: There was no significant difference in VO 2 peak between groups (MS: 30.8 ml/kg·min -1 vs CON: 28.2 ml/kg·min -1 , p=0.65). Both groups (MS and CON) had significant time (rest to peak) differences in SV (rest: MS = 74.6 ± 32.5 mL, CON = 65.7 ± 23.1 mL, peak: MS = 114.4 ± 42.4 mL, CON = 84.2 ± 33.3 mL; p&lt;0.001), HR (rest: MS = 65 ± 15 bpm, CON = 61 ± 10 bpm, peak: MS = 167 ± 13 bpm, CON = 175 ± 11 bpm; p&lt;0.001), Q (rest: MS = 4.7 ± 2.2 L/m, CON = 4.0 ± 1.3 L/m, peak: MS = 12.3 ± 5.0 L/min, CON = 12.3 ± 5.1 L/min; p&lt;0.001), and MAP (rest: MS = 84 ± 10 mmHg, CON = 83 ± 13 mmHg, peak: MS = 102 ± 7 mmHg, CON = 104 ± 17 mmHg, p &lt;0.001). There was also a significant group by time interaction in HR (p = 0.04), but no group by time interactions in SV, Q, or MAP. Finally, there was not significant difference in avO 2 diff between groups (MS: 2.3 ± 1.2 mL/100 mL vs CON: 2.7 ± 1.5 mL/100 mL). Conclusion: Our findings suggest that individuals with MS exhibit different cardiac hemodynamics to achieve maximal aerobic capacity than those without MS. Individuals with MS reached maximal Q via a slightly higher, although statistically non-significant, stroke volume but a lower HR. This suggests that people with MS may rely on different mechanisms for achieving VO2peak compared to controls, but future research is needed to elucidate this hemodynamic pattern. Department of Defense office of the Congressionally Directed Medical Research Program on Multiple Sclerosis This is the full abstract presented at the American Physiology Summit 2023 meeting and is only available in HTML format. There are no additional versions or additional content available for this abstract. Physiology was not involved in the peer review process.

Progressive changes in residual gradient after aortic coarctation repair and its role in the prediction of reintervention: A longitudinal data analysis.

Repair of aortic coarctation through left thoracotomy is the standard treatment when anatomically feasible. Long-term outcomes are well studied, including the need for reintervention. However, the timely variation in residual gradients across the repaired segment is ill-defined. The aim of this work was to study the progressive changes of estimated peak gradient (ePG) acquired by transthoracic continuous-wave Doppler echocardiography across the aortic arch after repair and to assess the role of timing of assessment and values of ePG in prediction of reintervention. All eligible patients for this study who underwent aortic coarctation repair through left thoracotomy from 2001 to 2017 were reviewed. Details of the aortic arch dimensions and associated lesions were obtained by transthoracic echocardiography (TTE). The primary outcome was the ePG across the aortic arch after repair. Longitudinal data analyses with mixed effect modeling were used to determine independent predictors for ePGs. A total of 312 patients were included. Median age and weight were 30 days and 4 kg, respectively. Associated lesions included ventricular septal defect (VSD) (53%), bicuspid aortic valve (53%) and mitral stenosis (25%). Over 15-years follow-up the freedom from reintervention was 92.3%, while 24 out of the 312 patients underwent reintervention (7.7%). Longitudinal data analyses of serial 2566 TTE studies were done. The graphical display showed that the ePG across coarctation area in the first postoperative TTE was the most notable difference between those who underwent reintervention and those who did not. Further testing with proportional hazard and logistic regression modeling confirmed this finding. The area under receiver operating curve statistics showed that an ePG of 25 mmHg is an optimal cutoff value for the prediction of the reintervention. The ePG acquired in the first postoperative TTE is the most important predictor for reinterventions. The presence of VSD is associated with decreased ePGs. We propose that an ePG in the first postoperative TTE of 25 mmHg or more is a strong predictor for the need of reintervention.

Abstract 14923: A Special Type Aortic Left Ventricular Tunnel With Bicuspid Aortic Valve: A Case Report

Introduction: Aortic-left ventricular tunnel (ALVT) is an extremely rare congenital cardiac lesion that is an abnormal passage connecting the ascending aorta to the left ventricle. ALVT can be diagnosed by the use of real-time two-dimensional and continuous-wave Doppler echocardiography. Case presentation: A two-year and seven-month-old boy with recently diagnosed influenza presented to the hospital because of severe tachypnea and fatigue after running. Physical examination revealed a grade 3/6 systolic and diastolic murmur at the second and third left intercostal space. Transthoracic echocardiography (GE E95 with a 5-MHz scanning head) demonstrated that the aortic valve was a bicuspid aortic valve (BAV) with mild-moderate insufficiency during diastole, the peak systolic velocity (PSV) and gradient of aortic valve were 1.9m/s and 14mmHg, respectively; The aortic sinotubular junction (ASJ) was stenotic, the PSV and gradient of ASJ were 2.7m/s and 29mmHg, respectively; A tubular-like structure originated in the outlet septum beneath the right coronary cusp and terminated in the ascending aorta superior to the right coronary aortic sinus (Fig. A, B), CDFI and continuous-wave Doppler showed unobstructed to-and-fro (systolic and diastolic) flow in the tunnel with a high-velocity color signal that aliased during systole (Fig. C-E). Clinical considerations for congenital heart disease: ALVT combines BAV with aortic insufficiency and supravalvar aortic stenosis. The patient was referred for possible surgical correction. Discussion: In this patient, the type of ALVT does not belong to any one of Hovaguimian’s classifications. Two-dimensional echocardiography can display the tunnel-like structure of ALVT in real-time, and CDFI can identify that two-stage bidirectional shunted blood flow, systolic ventricular ejection occurs through both the tunnel and the semilunar valve, and the diastolic flow reverses from the aorta to ventricle via ALVT.

Kat-ARC accelerated 4D flow CMR: clinical validation for transvalvular flow and peak velocity assessment

BackgroundTo validate the k-adaptive-t autocalibrating reconstruction for Cartesian sampling (kat-ARC), an exclusive sparse reconstruction technique for four-dimensional (4D) flow cardiac magnetic resonance (CMR) using conservation of mass principle applied to transvalvular flow.MethodsThis observational retrospective study (2020/21-075) was approved by the local ethics committee at the University of East Anglia. Consent was waived. Thirty-five patients who had a clinical CMR scan were included. CMR protocol included cine and 4D flow using Kat-ARC acceleration factor 6. No respiratory navigation was applied. For validation, the agreement between mitral net flow (MNF) and the aortic net flow (ANF) was investigated. Additionally, we checked the agreement between peak aortic valve velocity derived by 4D flow and that derived by continuous-wave Doppler echocardiography in 20 patients.ResultsThe median age of our patient population was 63 years (interquartile range [IQR] 54–73), and 18/35 (51%) were male. Seventeen (49%) patients had mitral regurgitation, and seven (20%) patients had aortic regurgitation. Mean acquisition time was 8 ± 4 min. MNF and ANF were comparable: 60 mL (51−78) versus 63 mL (57−77), p = 0.310). There was an association between MNF and ANF (rho = 0.58, p < 0.001). Peak aortic valve velocity by Doppler and 4D flow were comparable (1.40 m/s, [1.30−1.75] versus 1.46 m/s [1.25−2.11], p = 0.602) and also correlated with each other (rho = 0.77, p < 0.001).ConclusionsKat-ARC accelerated 4D flow CMR quantified transvalvular flow in accordance with the conservation of mass principle and is primed for clinical translation.

Transesophageal Echocardiography For The Assessment of Left Atrial Pressure After Trans-Septal Mitral Valve Interventions

The measure of left atrial pressure (LAP) is an ideal marker for the clinical efficacy of transcatheter mitral valve intervention. Currently, only the invasive measurement of LAP (i-LAP) is available and no echocardiographic methods are reliable in the setting of transcatheter mitral valve intervention. This study sought to validate a new echocardiographic method for the estimation of LAP (e-LAP) by comparing it with i-LAP. During percutaneous edge-to-edge procedure with MitraClip, the i-LAP was routinely monitored. Across the iatrogenic interatrial septum defect, the flow was sampled with continuous-wave Doppler echocardiography for deriving the mean pressure gradient between the left atrium and the right atrium, and the central venous pressure was added to obtain the e-LAP. The correlation between the measures derived from these 2 methods was explored. A total of 34 consecutive patients were included. Intraclass correlation coefficient between e-LAP and i-LAP was high (intraclass correlation coefficient [95% confidence interval] 0.809 [0.625 to 0.902], R Pearson 0.6, p <0.001); a bias of -1.3 mm Hg for e-LAP versus i-LAP was found (p=0.32). The median follow-up was 108 days (interquartile range 40 to 264). No death occurred and 6 patients were rehospitalized for heart failure. Postimplant e-LAP was correlated with rehospitalization at follow-up (hazard ratio 1.46, 95% confidence interval 1.022 to 2.1, p=0.038). A cut-off value of 9.5 mm Hg for the e-LAP was identified as predictor of rehospitalization for heart failure. The evaluation of e-LAP has optimal reliability compared with i-LAP; a value more than 9.5 mm Hg was found to be related to higher risk of events at short follow-up.

Abstract 11516: Quantification of Regurgitation Through Dual Orifices: Pulsatile in Vitro Analysis with Echocardiography and MRI Assessment

Introduction: Proximal Isovelocity Surface Area (PISA) measurement is widely accepted to quantify mitral regurgitant volume (RVol), but flow convergence (FC) zones are complicated with dual orifices, seen with mitral clipping. This study seeks to investigate how flow through one orifice affects PISA measurement across the other to better quantify RVol in dual orifice conditions. Methods: 3D-printed dual circular orifice models with varying relative areas were integrated into a pulsatile flow phantom simulating left heart flow. One orifice (A) was standardized at 19.6 mm 2 while the other (B) was 1X, 2X, and 3X the area of A in three models. Inter-orifice distance was 5 mm to emulate mitral clipping. Continuous wave doppler echocardiography measured peak velocity and velocity time integral. PISA was performed at four aliasing velocities normalized to peak velocity (V a /V peak ) (10%, 8%, 4%, 2%) to compute RVol with 2D phase contrast MRI as reference. In each model, PISA RVol and percent error was calculated to see how varying the area of B impacts PISA accuracy of A. 4D flow MRI FC data was also collected to visualize the 3D formation of FC zones. Results: Using a high V a /V peak to create distinct FC zones provides a better RVol estimation with PISA, as low V a /V peak will merge the FC zones, overestimating flow across individual orifices. Single factor analysis of variance (ANOVA) of percent error of A across the three models showed no significant difference at high V a /V peak (8%: p=0.80, 10%: p=0.23), but significant difference at low V a /V peak (2%: p=0.010, 4%: p=0.005). High V a /V peak FC zones of orifices are independent from each other; PISA can be measured with standard practices and added together for an accurate total RVol. At low V a /V peak , FC orifice zones overlap with overestimation error increasing with larger B area. This finding suggests that resolving two separate FC zones to minimize flow interference is important for accurate RVol estimate in a dual orifice setting.

Left intraventricular pressure gradient in hypertrophic cardiomyopathy patients receiving implantable cardioverter-defibrillators for primary prevention

BackgroundConventional risk factors for sudden cardiac death (SCD) justify primary prevention through implantable cardioverter-defibrillator (ICD) implantation in hypertrophic cardiomyopathy (HCM) patients. However, the positive predictive values for these conventional SCD risk factors are low. Left ventricular outflow tract obstruction (LVOTO) and midventricular obstruction (MVO) are potential risk modifiers for SCD. The aims of this study were to evaluate whether an elevated intraventricular pressure gradient (IVPG), including LVOTO or MVO, is a potential risk modifier for SCD and ventricular arrhythmias requiring ICD interventions in addition to the conventional risk factors among HCM patients receiving ICDs for primary prevention.MethodsWe retrospectively studied 60 HCM patients who received ICDs for primary prevention. An elevated IVPG was defined as a peak instantaneous gradient ≥ 30 mmHg at rest, as detected by continuous-wave Doppler echocardiography. The main outcome was a composite of SCD and appropriate ICD interventions, which were defined as an antitachycardia pacing or shock therapy for ventricular tachycardia or fibrillation. The Cox proportional hazards model was used to assess the relationships between risk factors and the occurrence of SCD and appropriate ICD interventions.ResultsThirty patients met the criteria of elevated IVPG (50%). During the median follow-up period of 66 months, 2 patients experienced SCD, and 10 patients received appropriate ICD interventions. Kaplan–Meier curves showed that the incidence of the main outcome was higher in patients with an IVPG ≥ 30 mmHg than in those without an IVPG ≥ 30 mmHg (log-rank P = 0.03). There were no differences in the main outcome between patients with LVOTO and patients with MVO. The combination of nonsustained ventricular tachycardia (NSVT) and IVPG ≥ 30 mmHg was found to significantly increase the risk of the main outcome (HR 6.31, 95% CI 1.36–29.25, P = 0.02). Five patients experienced ICD implant-related complications.ConclusionsOur findings showed that a baseline IVPG ≥ 30 mmHg was associated with an increased risk of experiencing SCD or appropriate ICD interventions among HCM patients who received ICDs for primary prevention. Combined with NSVT, which is a conventional risk factor, a baseline IVPG ≥ 30 mmHg may be a potential modifier of SCD risk in HCM patients.

Distinct pressure half-time values by transthoracic echocardiography for grading of paravalvular regurgitation after transcatheter aortic valve replacement

Postprocedural aortic regurgitation (AR) has negative impact on patient outcome after transcatheter aortic valve replacement (TAVR). Standard assessment of AR severity by echocardiography is hampered after TAVR. Measurement of pressure half-time (PHT) by echocardiography is not limited in these patients but it may be affected by concomitant left ventricular hypertrophy (LVH). This study sought to evaluate distinct cut-off values of PHT differentiating between patients without and with more than mild LVH for grading of AR after TAVR with cardiac magnetic resonance (CMR) as the reference method for comparison. 71 patients (age 81 ± 6 years) with severe aortic stenosis undergoing TAVR were included into the study. Transthoracic echocardiography (TTE) and CMR were performed after TAVR. Left ventricular mass index was calculated by TTE. PHT was measured by continuous-wave Doppler echocardiography of aortic regurgitation jet. In 18 patients (25%) PHT could not be obtained due to no or very faint Doppler signal. Aortic regurgitant volume and regurgitant fraction were calculated by CMR by flow analysis of the ascending aorta. In 14 of 53 patients (26%) AR after TAVR was moderate or severe as categorized by CMR analysis. More than mild LVH was present in 27 of 53 patients (51%). PHT correlated inversely less to regurgitant fraction by CMR analysis in patients with LVH (r = −0.293; p = 0.138) than in patients without LVH (r = −0.455; p = 0.020). In patients without relevant LVH accuracy of PHT to predict moderate or severe paravalvular regurgitation AUC was 0.813 using a cut-off value of 347 ms and AUC was 0.729 in patients with more than mild LVH using a cut-off value of 420 ms. Analysis of PHT by TTE with distinct cut-off values for patients without and with more than mild LVH allows detection of moderate or severe AR after TAVR as defined by CMR. In none of the patients in which PHT could not be measured AR was categorized as more than trace by CMR analysis.

Simple and noninvasive method to estimate right ventricular operating stiffness based on echocardiographic pulmonary regurgitant velocity and tricuspid annular plane movement measurements during atrial contraction

It was recently shown that invasively determined right ventricular (RV) stiffness was more closely related to the prognosis of patients with pulmonary hypertension than RV systolic function. So far, a completely noninvasive method to access RV stiffness has not been reported. We aimed to clarify the clinical usefulness of our new echocardiographic index of RV operating stiffness using atrial-systolic descent of the pulmonary artery-RV pressure gradient derived from pulmonary regurgitant velocity (PRPGDAC) and tricuspid annular plane movement during atrial contraction (TAPMAC). We studied 81 consecutive patients with various cardiac diseases who underwent echocardiography and cardiac catheterization. We measured PRPGDAC and TAPMAC using continuous-wave Doppler and M-mode echocardiography, respectively, and calculated PRPGDAC/TAPMAC. RV end-diastolic pressure (RVEDP) and RV pressure increase during atrial contraction (ΔRVPAC) were invasively measured, and RV volume change during atrial contraction (ΔVAC) was calculated from echocardiographic late-diastolic transtricuspid flow time-velocity integral and tricuspid annular area; thus ΔRVPAC/ΔVAC was used as the standard index for RV operating stiffness. PRPGDAC/TAPMAC well correlated with ΔRVPAC/ΔVAC (r = 0.84, p < 0.001) and RVEDP (r = 0.80, p < 0.001), and the area under the receiver operating characteristic curve to discriminate RVEDP > 12mmHg was 0.94. Multivariate regression analysis revealed that PRPGDAC/TAPMAC was the single independent determinant of ΔRVPAC/ΔVAC (β = 0.86, p < 0.001). PRPGDAC/TAPMAC is useful to estimate RV operating stiffness and a good practical indicator of RVEDP.

Coronary-Cameral Fistula: Preliminary Diagnosis According to Colour and Continuous Wave Doppler Echocardiography

Summary We present a rare case of an incidentally discovered right coronary-cameral fistula (CCF) to the left ventricle, with a diagnosis initially made based on contrast enhanced continuous wave (CW) Doppler echocardiography. Computed tomographic angiography, and later invasive coronary angiography, confirmed the diagnosis. Through a multi-modality approach including contrast enhanced CW Doppler, a diagnosis of CCF can be conclusively made.

Systolic aortic regurgitation in rheumatic carditis: Mechanistic insight by Doppler echocardiography

BackgroundAortic regurgitation (AR) usually occurs in diastole in presence of an incompetent aortic valve. Systolic AR is a rare phenomenon occurring in patients with reduced left ventricular systolic pressure and atrial fibrillation or premature ventricular contractions. Its occurrence is a Doppler peculiarity and adds to the hemodynamic burden. AimRheumatic carditis is often characterised by acute or subacute severe mitral regurgitation (MR) due to flail anterior mitral leaflet and elongated chords. In patients with acute or subacute MR, developed left ventricular systolic pressure may fall in mid and late systole due to reduced afterload and end-systolic volume and may be lower than the aortic systolic pressure, causing flow reversal in aorta and systolic AR. Material and methods17 patients with acute rheumatic fever were studied in the echocardiography lab during the period 2005–2015. Five patients had severe MR of which two had no AR and hence were excluded from the study. Three young male patients (age 8–24 years) who met modified Jones’ criteria for rheumatic fever with mitral and aortic valve involvement were studied for the presence of systolic AR. ResultsIn presence of acute or subacute severe MR, flail anterior mitral valve and heart failure, all three showed both diastolic and late systolic AR by continuous-wave and color Doppler echocardiography. ConclusionSystolic AR is a unique hemodynamic phenomenon in patients with acute rheumatic carditis involving both mitral and aortic valves and occurs in presence of severe MR.

Relationship between matrix metalloproteinase-3 serum level and pulmonary artery systolic pressure in patients with rheumatoid arthritis.

Activity of rheumatoid arthritis (RA) has been evaluated by various biomarkers including matrix metalloproteinase (MMP)-3, but the relationship between the levels of biomarkers and elevation of pulmonary artery systolic pressure (PAs) has not been evaluated in detail. We sought to determine the utility of MMP-3 with other biomarkers for the prediction of PAs in patients with RA. Blood samples for biomarkers and echocardiography were obtained in 100 consecutive patients with RA. PAs was measured by continuous-wave Doppler echocardiography and was correlated with laboratory findings. PAs had a fair correlation with MMP-3 (r=0.53, p<0.001) and a weak correlation with KL (Krebs von den Lungen)-6 (r=0.36, p<0.001) and rheumatoid factor (r=0.25, p=0.011). MMP-3 had a fair correlation with pulmonary vascular resistance (r=0.42, p<0.001), but MMP-3 was not related to cardiac output (r=0.09, p=0.352). Thirty-nine patients had impaired left ventricular diastolic function. There was no significant differences in PAs and pulmonary vascular resistance (PVR) between the patients with and without impaired left ventricular diastolic function. When 5 variables (age, MMP-3, C-reactive protein, KL-6, and rheumatoid factor) were used in the multivariate analysis, MMP-3 (partial regression coefficient=0.553, p<0.001) emerged as the most important variable related to the elevation of PAs. Nine patients (9%) were diagnosed to have pulmonary hypertension by echocardiography. MMP-3 value of 245ng/ml was the optimal cut-off value for the prediction of pulmonary hypertension (sensitivity: 100%, specificity: 67%, area under the curve 0.89). Thus, a close relation of MMP-3 with PAs and PVR indicate that rise in PAs in patients with RA was ascribed to increase in PVR due to underlying systemic inflammation-mediated pulmonary vascular remodeling.

Fetal Patient Foramen Ovule: Anatomical & Physiological Aspects

Conventionally, Patent Foramen Ovale (PFO) is known as an important pathway for the passing through from right atrium to left atrium. However, its exact anatomic and morphologic nature remain unclear. This study is thus to evaluate the morphologic characteristics of PFO using fetal echocardiography. I have studied Fetal foramen ovale for over 30 years. The gestational ages ranged between 16 and 42 weeks. All of the fetal echocardiography was performed using commercially available ultrasonographic plateform. The fetal echocardiographic examination included black-and-white 2 dimensional and M-mode, color flow 2 dimensional and M-mode, pulsed and continuous wave Doppler echocardiography. I have found showed that fetal PFO showed wide variation in their morphlology. But in general it consisted a central plate connected with other parts of atrial septum proper through many web-like strands or membrane, forming a pocket like structure. Our study showed that PFO, although well known for many of us, is not a simple “hole” as its name implies. The term of PFO appears more compatible to the post-natal appearance of this structure. Prenatally in the fetus, on 2 dimensional echocardiographic images, PFO actually appearsas an open basket facing the right atrium connected with the atrial septum.

Echocardiograms Estimated the Severity of Aorticstenosis (AS) Accompanied with Tachycardiac Arrhythmia (AATA)

patients accompanied with tachycardiac arrhythmia (Frequent premature ventricular arrhythmia, supraventricular tachycardia,atrial fibrillation, etc), estimated the severity of aorticstenosis under transthoracic echocardiography (TTE), using the methods as below: continuous-wave (CW) Doppler echocardiography estimated aortic jet speed (VAV) and across valve mean pressure difference (△Pmean), Doppler echocardiography estimated the effective aortic valve area (AVAeffective) and velocity ratio (VR=VLVOT/VAV) by using the continuity equation, 2D echocardiography estimated aortic valve geometric area in anatomy (AVAanatomy). And compared the stability, accuracy and clinical value of these methods. This was a review of 11 AATA cases that were diagnosed in our institution between November 2016 and January 2017. At the condition of tachycardiac arrhythmia, estimating VAV, △Pmean, AVAeffective, VR and AVAanatomy under TTE. At the condition of normal arrhythmia under cardiopulmonary bypass during the surgery, estimating VAV, △Pmean, AVAeffective, VR and AVAanatomy once more under transesophageal echocardiography (TEE). And also, estimating AVAanatomy intraoperative exploration. In order to decrease the measurement error, we measured every values at lest three times and choose the mean value. Compared with the values estimated under normal arrhythmia, at the condition of AATA (with the severity of AS at moderately to severely), the value of VAV and △Pmean have differences (P < 0.05), easy to underestimate the severity of AS; the value of AVAeffective and VR have differences (P < 0.05), easy to overestimate the severity of AS; the value of AVAanatomy, which often greater than the value of AVAeffective, has no obvious difference and has good consistency with the geometric area of aortic measured intraoperative exploration. When estimating the severity of AS at the condition of AATA under TTE, the methods of assessment by Doppler echocardiography often instability, easy to underestimate or overestimate because of the affection of the ventricular rate. While the method of assessment by 2D echocardiography seemed to be less sensitive to the ventricular rate, so that could be a more reliable method in estimating the severity of AS at AATA and have clinical significance, although it has some differences with the value of AVAeffective.

Evaluation of Intravascular Hemolysis With Erythrocyte Creatine in Patients With Aortic Stenosis

Chronic intravascular hemolysis has been identified in patients with cardiac valve prostheses, but only a few case reports have evaluated intravascular hemolysis in patients with native valvular heart disease. To detect intravascular hemolysis in patients with aortic stenosis, erythrocyte creatine was evaluated with hemodynamic indices obtained by echocardiography.Erythrocyte creatine, a marker of erythrocyte age, was assayed in 30 patients with aortic stenosis and 10 aged matched healthy volunteers. Peak flow velocity of the aortic valve was determined by continuous-wave Doppler echocardiography. Twenty of 30 patients with aortic stenosis had high erythrocyte creatine levels (> 1.8 µmol/g Hb) and erythrocyte creatine was significantly higher as compared with control subjects (1.98 ± 0.49 versus 1.52 ± 0.19 µmol/g Hb, P = 0.007). Peak transvalvular pressure gradient ranged from 46 to 142 mmHg and peak flow velocity ranged from 3.40 to 5.95 m/second. Patients with aortic stenosis had a significantly lower erythrocyte count (387 ± 40 versus 436 ± 42 × 10(4) µL, P = 0.002) and hemoglobin (119 ± 11 versus 135 ± 11 g/L, P < 0.001) as compared with control subjects. Erythrocyte creatine had a fair correlation with peak flow velocity (r = 0.55, P = 0.002).In conclusion, intravascular hemolysis due to destruction of erythrocytes was detected in patients with moderate to severe aortic stenosis and the severity of intravascular hemolysis was related to valvular flow velocity of the aortic valve.

Gözden Kaçırma Ölümcül Olabilir; Apikal Anevrizma ile İlişkili Ventrikül Ortası Darlığı Olan Hipertrofik Kardiyomiyopati

Mid-ventricular obstructive hypertrophic cardiomyopathy(MVOHCM) is a rare type of cardiomyopathy that can be accompanied by apical aneurysm. MVOHCM was demonstrated to have caused cardiac arrhytmias and sudden cardiac death. The identification of high-risk patients with hypertrophic cardiomyopathy (HCM) for primary prevention of sudden cardiac death (SCD) remains a challenging issue, since major risk factors sometimes lack specificity. We report the case of a patient who presented with ventricular fibrillation, ST-segment elevation on electrocardiography, and cardiac-enzyme elevation, in the presence of normal coronary arteries. Continuouswave Doppler echocardiography revealed a pressure gradient between the apical and basal chambers of the left ventricle.

Pulmonary Arterial Hypertension in Graves’ Disease

Background: Cardiovascular manifestations in Graves’ disease (GD) occur frequently with various phenotypes. A link between GD and pulmonary hypertension has been reported. There is limited data about prevalence PAH and related factors in GD in Indonesia. Objective: To identify the prevalence and related factors of PAH in GD. Method: This retrospective study is using secondary data from transthoracic echocardiographic database of General Hospital since last year. PAH was measured by continuous-wave Doppler echocardiography (pulmonary artery systolic pressure >35 mmHg). Sixty five patients who were diagnosed as GD were enrolled to study participant. Results: Of 65 eligible participants consist of 52 female and 13 male and median ages 42 year old (18–66 year old). Cardiac abnormalities were encountered in 79% participant of which consist of PAH in 15.4%. The patients with pulmonary hypertension had significantly higher pulmonary vascular resistance (PVR), cardiac output compared to those without (p < 0.001 and p < 0.021 respectively). The possible explanations in addition to the effect of thyroid hormone on the cardiovascular system, autoimmune-mediated pulmonary vascular remodeling may play a role in Graves’ disease-linked elevated pulmonary artery systolic pressure. Conclusion: The prevalence of PAH in GD was 15.4%. There is still needed future research to know the factors related to PAH especially related to clinical and laboratory abnormalities in GD.

Quantitative and Pattern Analyses of Continuous-Wave Doppler–Derived Pulmonary Regurgitant Flow Velocity for the Diagnosis of Constrictive Pericarditis

Many echocardiographic features of constrictive pericarditis (CP) have been reported, but each alone has a limitation either in sensitivity or in specificity. Continuous-wave Doppler-derived flow velocity of pulmonary regurgitation can reflect the diastolic right ventricular pressure pattern characteristic of CP and be useful for its detection. Fifteen patients with CP, 18 patients with restrictive cardiomyopathy, and 20 normal subjects were studied retrospectively. Using continuous-wave Doppler echocardiography, pulmonary regurgitation velocities were measured at the early diastolic peak (VMAx), mid-diastolic inflection point (VIFL), and late diastolic minimal point (VMIN). VIFL, VIFL/VMAx, VMIN, and VMIN/VMAx were significantly lower in the CP group compared with the restrictive cardiomyopathy and normal groups. Prevalence rates of patients with early mid-diastolic inflection, VIFL/VMAx < 0.5, VMIN < 50 cm/sec, and VMIN/VMAx < 0.33 were significantly greater in the CP group compared with the other groups. Sensitivity and specificity for the diagnosis of CP were 93% and 74%, respectively, forthe presence of early mid-diastolic inflection, 73% and 100% for VIFL/VMAx < 0.5, 73% and 97% for VMIN < 50 cm/sec, and 93% and 92% for VMIN/VMAx < 0.33. The quantitative and pattern analyses of continuous-wave Doppler-derived pulmonary regurgitation velocity could enhance the accuracy of echocardiographic detection of CP.