2-dimensional Doppler Echocardiography Research Articles

Diagnosis: Pulmonary Hypertension. Next Steps.

Pulmonary hypertension (PH) is a disease that is generally first encountered by primary care physicians. Usually, patients present with dyspnea on exertion and a loss of exercise tolerance, although they can have symptoms of chest discomfort, syncope, or edema. Most patients are diagnosed with 2 dimensional doppler echocardiography although echo is not 100% sensitive nor specific in making this diagnosis. Note that the diagnostic criteria for this disease have changed recently. Most patients develop pulmonary hypertension secondary to left heart failure, or to pulmonary disease with or without hypoxemia. Ultimately, many patients require right heart catheterization for diagnosis and for proper treatment. This is best performed by those that specialize in management of this disease. It is important to diagnose patients who have pulmonary hypertension due to pulmonary artery hypertension and patients with chronic thromboembolic pulmonary hypertension as these patients require specialized treatment that is most effective if started early in the disease course. This review discusses issues related to diagnosis and appropriate referral of patients with pulmonary hypertension.

Impact of active fluid management on cardiac hemodynamic and mechanics in patients on maintenance hemodialysis

Background/Aim. Overhydration (OH) and shortcomings of clinical assessment of so called ?dry weight? in hemodialysis (HD) patients are well known risk factors for high cardiovascular morbidity and mortality in this population. The purpose of this prospective randomized study was to investigate possible benefits of the active fluid management (AFM) guided by bioimpedance spectroscopy (BIS) on cardiac morphology, mechanics and function in chronic hemodialysis patients. Methods. The study lasted 9 months and 83 BIS naive patients were enrolled. Cardiac structural and functional characteristics were obtained using two dimensional Doppler echocardiography and global strains by speckle tracking modality. In addition, cardiac markers were measured. Results. Seventy three patients completed the study (38 in the active ? AFM group and 35 in the control group). At the end of the study, the main structural change in the active group of patients was reduction of left ventricular mass index (from 62.81 ? 19.74 g/m2.7 to 57.74 ? 16.87g/m2..7; p = 0.007), while main functional improvements in this group were better left ventricular ejection fraction (LVEF; from 41.27 ? 9.26% to 43.95 ? 8.84%; p = 0.006) and fractional shortening (FS; 27.86 ? 5.94% to 29.86 ? 5.83%; p = 0.056) in accordance with improvement of radial left ventricular (LV) mechanics detected by higher global radial strain (GRS) (18.56 ? 10.24% to 21.79 ? 12.16%; p = 0.014). The diastolic function of patients in the control group worsened significantly, assessed as ratio of Doppler velocity of early diastolic filling of left ventricle ? E, and average velocity of tissue Doppler measured at lateral part of the mitral annulus (e? lateral; E/e? lateral ratio 10.59 ? 5.00 to 11.12 ? 4.06; p = 0.036) and consecutively the right ventricular systolic pressure (RVSP) estimated indirectly by echocardiography: from 34.84 ? 10.18 mmHg to 38.76 ? 8.34 mmHg; p = 0.028. These functional changes were in correlation with significantly higher levels of Nterminal prohormone brain natriuretic peptide (NTproBNP) in this group of patients [median and interquartile range (IQR): 5810.0 pg/mL (3339.0?15627.0 pg/mL) to 8024.0 pg/mL (4433.0?17467.0 pg/mL; p = 0.038)]. The improvement in the LV structure and function in the active group correlated with better relative overhydration (ROH) management in this group ? the proportion of ?critically? overhydrated patients decreased from 45% at the start to 24% at the end of study (p = 0.003). At the end of the study, there were 49% of post-dialysis ?critically? dehydrated patients in the control group. Proportion of anuric patients increased only in the control group (63% to 77%; p = 0.063). Conclusion. Active fluid management, guided by bioimpedance spectroscopy had positive impact on cardiac hemodynamics and mechanics in our study patients and could improve clinical decisions regarding their optimal weight and further clinical course. Further data from well designed studies are needed urgently.

The experience of surgical treatment for Ebstein anomaly in 141 children

Objective: To explore the surgical strategy for Ebstein anomaly in children. Methods: From January 2003 to December 2015, a total of 141 cases of Ebstein anomaly were treated at Department of Pediatric Cardiothoracic Surgery, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiaotong University. There were 65 male and 76 female patients, with age of (6.9±1.6) years (ranging from 10 months to 15 years), weight of (19.6±4.7) kg (ranging from 6.5 to 59.0 kg). All patients were diagnosed by 2 dimensional Doppler echocardiography and the septal leaflet and posterior leaflet displaced downward from 1.0 to 5.0 cm. The tricuspid valve regurgitation (TR) were mild in 26 cases, moderate in 46 cases and severe in 69 cases. Tricuspid valvuloplasty were performed in 131 cases (94 cone reconstruction, 37 valve hoist), tricuspid valve replacement in 2 cases and tricuspid valve closed in 8 cases. Surgical strategy were divided into biventricular heart function in 77 cases, one and a half ventricular heart function in 56 cases, and single ventricular heart function in 8 cases. Results: Three patients were changed to one and a half ventricular repair from biventricular repair due to unstable hemodynamics in the early postoperative period. One case died in biventricular group. The complete atrioventricular block were occurred in 3 patients and pacemaker were applied. One hundred and forty cases discharged from hospital. There were mild TR in 118 cases, moderate in 14 cases and closed in 8 cases. One hundred and thirty-seven cases were followed up regularly in 18 to 172 months. Ninety-one cases were treated by cone reconstruction (mild TR in 75 cases, moderate in 15 cases and severe in 1 case). Thirty-six cases were operated by tricuspid valve hoist (mild TR in 21 cases, moderate in 12 cases and severe in 3 cases). In the patients with severe TR (4 cases), 3 cases were reoperated by cone reconstruction. One case's valve was closed because of the dysplasia of the anterior valve and then from one and a half ventricular heart function to single ventricular function, the oxygen saturation was increased. Two patients underwent tricuspid valve replacement, 1 died and the other's mechanical valve was removed, and changed to single ventricular function repair. Conclusions: Although tricuspid cone reconstruction can achieve good results, the stable hemodynamic of early postoperative can be effectively maintained by using the surgical strategy of one and a half ventricular repair. To the patients with severe tricuspid regurgitation and hypoxemia due to severe tricuspid valve dysplasia, transforming to a functional single ventricle may be the only choice when there comes to the unstable hemodynamic.

Massive Pulmonary Embolism in a Pregnant Woman with an Excellent Response to Early Thrombolytic Therapy

Thrombolytic agents have been used successfully to treat patients with massive pulmonary embolism and cardiorespiratory insufficiency. Experience with these drugs in pregnancy is limited, nevertheless. We report a 32-year-old pregnant female, who was at 16 weeks of gestation, presented with acute collapse and progressive dyspnea caused by massive pulmonary embolism. The diagnosis was rapidly made in the emergency department with two dimensional-doppler echocardiography that showed signs of right ventricular dysfunction and pulmonary hypertension, as well as direct visualisation of large thrombus at the bifurcation of the main pulmonary artery. Because of significant haemodynamic instability and no improvement after intravenous heparin, the patient was successfully treated with recombinant tissue plasminogen activator and low-molecular-weight heparin. The response to fibrinolytic therapy was excellent without haemorrhagic complications and a healthy child was born at term. We conclude that early thrombolytic therapy may be a reasonable treatment for pregnant patients with unstable pulmonary embolism. (Hong Kong j.emerg.med. 2014;21:260-265)

Ascending Aortic Constriction in Rats for Creation of Pressure Overload Cardiac Hypertrophy Model

Ascending aortic constriction is the most common and successful surgical model for creating pressure overload induced cardiac hypertrophy and heart failure. Here, we describe a detailed surgical procedure for creating pressure overload and cardiac hypertrophy in rats by constriction of the ascending aorta using a small metallic clip. After anesthesia, the trachea is intubated by inserting a cannula through a half way incision made between two cartilage rings of trachea. Then a skin incision is made at the level of the second intercostal space on the left chest wall and muscle layers are cleared to locate the ascending portion of aorta. The ascending aorta is constricted to 50-60% of its original diameter by application of a small sized titanium clip. Following aortic constriction, the second and third ribs are approximated with prolene sutures. The tracheal cannula is removed once spontaneous breathing was re-established. The animal is allowed to recover on the heating pad by gradually lowering anesthesia. The intensity of pressure overload created by constriction of the ascending aorta is determined by recording the pressure gradient using trans-thoracic two dimensional Doppler-echocardiography. Overall this protocol is useful to study the remodeling events and contractile properties of the heart during the gradual onset and progression from compensated cardiac hypertrophy to heart failure stage.

Ascending Aortic Constriction in Rats for Creation of Pressure Overload Cardiac Hypertrophy Model

Ascending aortic constriction is the most common and successful surgical model for creating pressure overload induced cardiac hypertrophy and heart failure. Here, we describe a detailed surgical procedure for creating pressure overload and cardiac hypertrophy in rats by constriction of the ascending aorta using a small metallic clip. After anesthesia, the trachea is intubated by inserting a cannula through a half way incision made between two cartilage rings of trachea. Then a skin incision is made at the level of the second intercostal space on the left chest wall and muscle layers are cleared to locate the ascending portion of aorta. The ascending aorta is constricted to 50–60% of its original diameter by application of a small sized titanium clip. Following aortic constriction, the second and third ribs are approximated with prolene sutures. The tracheal cannula is removed once spontaneous breathing was re-established. The animal is allowed to recover on the heating pad by gradually lowering anesthesia. The intensity of pressure overload created by constriction of the ascending aorta is determined by recording the pressure gradient using trans-thoracic two dimensional Doppler-echocardiography. Overall this protocol is useful to study the remodeling events and contractile properties of the heart during the gradual onset and progression from compensated cardiac hypertrophy to heart failure stage.

121 CHANGES IN ENERGY LOSS AND PRESSURE RECOVERY AFTER BIOPROSTHESIS REPLACEMENT FOR AORTIC STENOSIS

<h3>Objectives</h3> Energy loss was shown to provide a more accurate assessment than pressure gradient or effective orifice area for aortic stenosis or prosthesis, as the former takes the pressure recovery into account while the later only measures the vena contracta orifice area. The present study aimed to elucidate the medium term changes in aortic prosthesis energy loss after aortic valve replacement (AVR) and compared with that of pressure gradient. <h3>Methods</h3> 76 patients (72±7 years, 46 males) underwent AVR for aortic stenosis were prospectively studied using echocardiography up to 3 years. Its mean systolic pressure gradient, effective orifice area and LV mass were determined by two dimensional Doppler echocardiography. Aortic sino-tubular junction diameter, aortic EOA and pressure gradient were used to calculate aortic valve energy loss (Garcia D, <i>et al</i>., <i>Circulation</i> 2000;101:765–71). <h3>Results</h3> In aortic stenosis, its pressure gradient recovery was only 28±9%. Thus, for mean pressure gradient of 41.0±16.7 mm Hg, the mean net energy loss is 32.1±14.3 mm Hg. Three years after AVR, the mean pressure gradient fell to 7.7±3.5 mm Hg, and the energy loss reduced to 4.6±2.4 mm Hg, both p&lt;0.001 vs pre-AVR. The percentage of pressure gradient recovery has increased to 61±14% (p&lt;0.001), which is inversely correlated with aortic sino-tubular junction diameter and positively correlated with EOA (p&lt;0.01, p&lt;0.01, r=0.90). LV mass index regressed from pre-AVR (182±48 g/m²) towards normal level (126±31 g/m²), p&lt;0.001. <h3>Conclusions</h3> AVR not only significantly reduced aortic valve pressure gradient itself, but has doubled the proportion of pressure recovery. This resulted in continuously low prosthesis energy loss and satisfactory LVH regression. As the sino-tubular junction diameter significantly affects aortic valve energy loss, restoring normal root geometry should be considered as one of the objectives for aortic valve surgery.

The Serum NT-proBNP in Patients with Cirrhosis: Relationship to Cardiac Dysfunction and Liver Function

Abstract Objective To detect the values of NT-proBNP and evaluate its relationship with liver function, cardiac structure, and cardiac function which was evaluated by echocardiography in patients with liver cirrhosis. Methods A total of 50 liver cirrhotic patients and 11 healthy controls were studied by two dimensional Doppler echocardiography. Liver cirrhotic patients were divided into group A, B and C according to the Child-Pugh score. Cardiac dimensions and left and right ventricular functions were also evaluated. At the same time, the serum NTproBNP of liver cirrhotic patients and healthy controls were detected, respectively. Results By Comparison between two groups, we found that the values of LVd, LAs, LVPW, AAO, A Wave, RVOTs, PV and NT-proBNP in liver cirrhosis group were higher than those in control group, whereas the value of E/A decreased. As for the value of LAs and serum NT-proBNP, A and B group were all lower than C group. With LAs &gt; 35 mm, the number of cases in liver cirrhosis group was higher than that in control group. So did that With E/A &lt; 1. Conclusions The cardiac dysfunction confirmed the existence of cirrhotic cardiomyopathy. More clinical implications were found in liver cirrhotic patients with increased values of serum NT-proBNP.

Late sequelae of penetrating cardiac injuries

Fifty-four patients who survived a penetrating cardiac injury were assessed for late cardiac complications. The mean follow-up after injury was 23 months. Clinical history and physical examination suggested cardiac complications in nine patients (17 per cent). Electrocardiogram was abnormal, but usually not diagnostic, in 17 (31 per cent). Routine two dimensional Doppler echocardiography revealed abnormalities in 17 (31 per cent). Ten patients (19 per cent) had valvular or septal defects. Other abnormalities included pericardial effusion, ventricular and septal dysfunction, and ventricular dilatation. Although it is impossible to determine how many of these abnormalities were post-traumatic, it seems that the incidence of late sequelae of cardiac injuries is high, and it is recommended that routine late follow-up of these patients should be done. Assessment should include routine echocardiograms.

Obese hypertensive rabbits develop concentric and eccentric hypertrophy and diastolic filling abnormalities

We have developed a new small animal model of obesity in which rabbits fed a high fat diet develop abnormalities in common with obese humans, including left ventricular (LV) hypertrophy. Using M-mode and two dimensional Doppler echocardiography we examined the characteristics of LV hypertrophy and diastolic function in obese and lean rabbits. Obese rabbits had greater interventricular septum and LV posterior wall thicknesses and greater LV internal end-diastolic and end-systolic diameters. Functionally, obese rabbits had higher A/E ratios. Similarly to obese humans, obese hypertensive rabbits develop combined concentric and eccentric LV hypertrophy and diastolic filling abnormalities. Therefore, this model may be valuable in the study of the development and pathology of obesity-related LV hypertrophy.

Signal processing in 2 dimensional Doppler echocardiography.

Blood flow recordings made by 2 dimensional Doppler echocardiography can sometimes be understood more easily than conventional Doppler recordings, because of the anatomical 2 dimensional presentation. In contrast, signal processing has become more complicated and requires more explanation. In 2 dimensional Doppler echocardiography the analog ultrasonic signal received by the transducer is converted into an audible signal, which next is digitized and analyzed for its mean frequency and variance. Data collection and processing require application of multigating and high speed frequency analysis, generally based upon autocorrelation. Some artifacts may be perceived, such as color reversal due to aliasing, deceptively colored tissue surfaces due to beam motion, and wall motion ghost signals due to multiple reflections. Color flow imaging is appropriate for a rapid scan of the heart cavities to detect and roughly evaluate flow abnormalities. Quantification is still accomplished by switching to conventional Doppler mode.

Mitral regurgitation in hypertrophic cardiomyopathy. Non-invasive study by two dimensional Doppler echocardiography.

Mitral regurgitation and its haemodynamic features were investigated non-invasively in cases of hypertrophic cardiomyopathy by means of two dimensional Doppler echocardiography. There were 28 patients, 14 of whom showed systolic anterior motion (SAM) of the mitral echo; the other 14 did not. The following results were obtained. (1) Mitral regurgitation was detected by the Doppler technique in all cases with systolic anterior motion of the mitral echo and in half of those without it. (2) Doppler signals of mitral regurgitation started immediately after the first heart sound. (3) Mitral regurgitant flow was often distributed from the entire mitral orifice over the entire or the posterior half of the left atrium in the cases with systolic anterior motion. In the cases without systolic anterior motion the regurgitation was usually localised near the mitral orifice. These features differ from those of regurgitation usually seen in rheumatic mitral valve disease and idiopathic mitral valve prolapse. (4) The Doppler technique and left ventriculography were equally efficient in detecting mitral regurgitation. (5) The early systolic component of the murmur of hypertrophic myopathy is considered to result in the main from concomitant mitral regurgitation, but not from turbulent blood flow in the left ventricular outflow tract, so that in cases with mitral regurgitation as a complication, mitral regurgitation may also contribute to the development of the midsystolic portion of the systolic murmur, while the main origin of this portion of the murmur is the left ventricular outflow obstruction.

Ultrasonography of the pelvic organs in prepubertal and postpubertal girls.

Reference curves for the growth of the uterus and ovaries were established for prepubertal and postpubertal girls by examining 34 healthy schoolgirls of age 7, 10, 13, and 17 years by grayscale ultrasound. Uterine volume increased from mean 0.9 cm3 at 7 years to 53 cm3 at 17 years. The ovaries could not be detected by ultrasound in girls of 7 years, but ovarian volume increased from mean 0.7 cm3 at 10 years to 5.8 cm3 at 17 years. There was good correlation between the Tanner score and uterine and ovarian volumes (r = 0.91 and 0.82 respectively). To test the reference curve, the uterine volume was assessed in 10 girls with abnormal sexual development. Five girls with precocious puberty had values greater than mean + 2 SD and 5 girls with primary amenorrhoea had values less than mean - 2 SD. Good reference values for ovarian and uterine size are necessary before ultrasound can be used to evaluate these organs in children with abnormal development of the reproductive system.