Noninvasive Cardiology Research Articles

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

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

The clinical benefits of adding a third dimension to assess the left ventricle with echocardiography.

Three-dimensional echocardiography is a novel imaging technique based on acquisition and display of volumetric data sets in the beating heart. This permits a comprehensive evaluation of left ventricular (LV) anatomy and function from a single acquisition and expands the diagnostic possibilities of noninvasive cardiology. It provides the possibility of quantitating geometry and function of LV without preestablished assumptions regarding cardiac chamber shape and allows an echocardiographic assessment of the LV that is less operator-dependent and therefore more reproducible. Further developments and improvements for widespread routine applications include higher spatial and temporal resolution to improve image quality, faster acquisition, processing and reconstruction, and fully automated quantitative analysis. At present, three-dimensional echocardiography complements routine 2DE in clinical practice, overcoming some of its limitations and offering additional valuable information that has led to recommending its use for routine assessment of the LV of patients in whom information about LV size and function is critical for their clinical management.

Subacute Transcatheter CoreValve Thrombotic Obstruction

An 86-year-old man with severe symptomatic aortic stenosis (additive Euroscore 7) underwent a transcatheter aortic valve implantation with a CoreValve bioprosthesis (26 mm, CoreValve Revalving Technology, Medtronic, Inc., Minneapolis, MN). The patient was discharged on aspirin and clopidogrel and advised to stop the clopidogrel after 3 months. This first 6-month follow-up was uneventful. Repeated echocardiograms obtained during this period revealed a slight increase in mean transprosthetic aortic pressure gradient without significant concomitant aortic regurgitation. At the last visit, 1 year later, the patient became symptomatic (New York Heart Association class II–III). He had no fever. Between the 6th and 12th month of follow-up, there was a documented increase in transprosthetic aortic peak velocity (4.11 m/s) and mean gradient (41 mm Hg) and a significant reduction in aortic effective orifice area (0.69 cm2), which indicated severe prosthetic valve stenosis. To evaluate the shape of the CoreValve, both transesophageal echocardiogram and cardiac computed tomography were performed. Although computed tomography revealed no change in prosthesis position (when compared with pre–transcatheter aortic valve implantation computed tomography) and the absence of significant deformation of the stent by any calcifications (Figure 1A–1D), transesophageal echocardiogram evidenced thickened …

Abstract 341: The Revascularization Heart Team: Feasibility and Cross-sectional Patient Profile in a Large Academic Center

The American College of Cardiology guidelines assign a Class IC recommendation for the use of a Heart Team approach in the treatment of complex coronary artery disease (CAD). However, doubts remain regarding the practical application and functionality of this method in providing routine cardiovascular care. We sought to assess the feasibility of the Heart Team approach to adjudicate complex CAD through analyzing personnel participation, as well as anatomic and comorbid patient characteristics. From May to October, 2012 we convened a daily Heart Team meeting to discuss evidence based management of patients with complex CAD. All cases were comprehensively reviewed by a team of interventional cardiologists, non-invasive cardiologists, cardiac surgeons, and anesthesiologists within 72 hours of angiography in our health system. Meetings occurred on average 3.5 days per week and included an average of 4 physicians from the multidisciplinary team. Patient profiles are detailed in Table 1. Recommendations for treatment were made based on a consensus decision amongst the group, and ultimately 20% of patients received medical therapy, 26.4% underwent percutaneous coronary intervention (PCI), 38.2 % had coronary bypass with or without valve repair or replacement, 0.9% went for minimally invasive direct coronary artery bypass, and 2.7% were treated with a hybrid procedure including PCI followed by surgery. We found a structured Heart Team approach to be feasible, and effective in formulating revascularization strategies for individual patients. This represents a successful model for the implementation of the Heart Team in routine care, which has great potential to positively influence quality of care. Further analyses are being explored to evaluate the impact of the Heart Team on patient outcomes.

The World Post-STICH: Is This A “Game Changer?” A Non-Invasive Cardiologist's Perspective—Revascularization Is The Treatment of Choice Only In Patients Who Fail Medical Therapy

The optimal management for ischemic cardiomyopathy has been a clinical conundrum for years. Until the publication of the Surgical Treatment of Ischemic Cardiac Heart Failure (STICH) trial, recommendations have been primarily based upon expert opinion, retrospective literature, and clinical anecdotes. However, medical and device management have matured significantly in an era where surgical morbidity and mortality remain significant for coronary bypass grafting in the setting of severe left ventricular dysfunction. For the first time in years, there now exists a landmark prospective randomized clinical trial that addresses the role of coronary bypass surgery as an initial strategy for ischemic cardiomyopathy. Although many interpretations of STICH exist, the neutral results of STICH should reassure clinicians that a strategy of initiating and optimizing medical therapy and deferring surgical revascularization for ischemic cardiomyopathy in “STICH-like patients” is effective, safe, and tested.

The Central Role of the Nurse in Process Improvement Relating to Pharmacologic Stress Testing

Pharmacologic stress myocardial perfusion imaging is a noninvasive method for evaluating coronary artery disease in patients unable to exercise sufficiently to achieve a heart rate high enough to facilitate satisfactory imaging. The nuclear cardiology nurse is an invaluable member of the laboratory team that performs these tests. In this specialist role, the nurse must have a thorough knowledge of the different pharmacologic stress agents (dipyridamole, adenosine, regadenoson, and dobutamine) that can be used. This should comprise an understanding of their mechanisms of action, contraindications, drug-drug interactions, adverse effects, and administration protocols. By drawing on this knowledge, the nurse is able to verify that the right agent has been selected for each patient based on his/her medical history. The nurse also can help patients follow pretest instructions (such as withholding caffeine and certain medications) by explaining that the measures are necessary for a safe and successful procedure and that violation may result in test cancellation or postponement. On the day of the stress test, the nurse has an important role in safeguarding the patient as well as providing support and reassurance throughout the different stages of the examination. Responsibilities include explaining the entire procedure to the patients, notably, what they will be asked to do, the effect of the stress agent, the timing of each step, the adverse effects that they may experience, how any adverse events will be managed, and the importance of remaining still during imaging. This central role of the nuclear cardiology nurse in overseeing the practical aspects of the pharmacologic stress test has important implications in terms of optimizing the productivity and efficiency of their noninvasive cardiology laboratory and nuclear medicine department.

2012 American college of cardiology foundation/society for cardiovascular angiography and interventions expert consensus document on cardiac catheterization laboratory standards update: American college of cardiology foundation task force on expert consensus documents society of thoracic surgeons society for vascular medicine

2012 American college of cardiology foundation/society for cardiovascular angiography and interventions expert consensus document on cardiac catheterization laboratory standards update: American college of cardiology foundation task force on expert consensus documents society of thoracic surgeons society for vascular medicine

Clinical expert consensus statement on best practices in the cardiac catheterization laboratory: Society for cardiovascular angiography and interventions

The cardiac catheterization laboratory (CCL) is a setting in which elective, urgent, and emergent percutaneous procedures are performed. This poses challenges to maintaining and prioritizing high quality care and patient safety. Nonetheless, process expectations of a high-quality CCL include appropriate periprocedural communication, clinical management, documentation, and universal protocol. Regulations primarily targeted at open surgical operating rooms have the potential to negatively impact care because they may mandate focus on performance measures that are not necessarily relevant to the cardiac catheterization laboratory. For example, routine site marking for percutaneous access is irrelevant for most patients since failure to obtain access on one side (e.g., right femoral artery) simply leads to attempting access on the other side (e.g., left femoral artery). Instead, directives should be tailored to the percutaneous procedure setting to assure quality and optimal patient safety. This document will therefore provide expert consensus opinion on a number of issues pertaining to ‘‘best practices’’ within the CCL, focusing on quality and safety during each step of the process. The writing committee acknowledges a dearth in high-quality published studies in this area, making many of the enclosed recommendations based primarily on expert consensus. Although references are provided when available, further research specifically in catheterization laboratory processes and quality improvement is needed. The document is divided into ‘‘best practices’’ that should be performed during the preprocedure, intraprocedure, and postprocedure settings for diagnostic cardiac catheterization and coronary intervention, to be consistent with the typical patient flow into and out of the CCL. Despite the long history of cardiac catheterization that dates back several decades, a document describing these ‘‘best practices’’ has not yet been written. The purpose of this document is not to represent all acceptable practices, but to provide consensus opinion on what would currently be considered ‘‘best practices’’ as future goals for catheterization laboratories.

Risk Stratification in Acute Coronary Syndromes

Accurate and readily available systems for risk stratification and a wide array of antithrombotic agents, on top of classical anti-ischemic drugs, provide the noninvasive cardiologist admitting the patient in the CCU with an effective and reliable armamentarium for the safe management of most patients with ACS. From the interventionalist's perspective, the immediate knowledge of the coronary anatomy yields the most valuable information to address the most appropriate treatment. The sooner angiography is performed the higher the benefit for patients at moderate to high risk, but if performed by expert teams and with the correct use of modern drugs and devices, the invasive approach has the potential to reduce costs and length of hospital stay also in low-risk patients. Although still some reluctance remains to equalize treatment strategies for patients with STEMI to those with NSTEMI, such differences will likely disappear in the near future with upcoming new evidence. Cardiac surgery may represent a life-saving alternative for patients presenting with NSTEMI evolving in cardiogenic shock or with mechanical complications, or in patients unsuitable for PCI or with failed PCI attempts. In stabilized conditions after the treatment of the culprit lesion, patients with severe multivessel disease may benefit from cardiac surgery to complete myocardial revascularization. Indications for CABG in this setting should be evaluated in the context of a local "heart team" or through prespecified protocols in centers without cardiac surgery on site.

Percutaneous coronary intervention of unprotected left main coronary artery disease

Data have emerged demonstrating the safety and efficacy of percutaneous coronary intervention (PCI) of the unprotected left main (ULM) artery. The 2009 American College of Cardiology/American Heart Association/Society for Cardiovascular Angiography and Interventions focused guidelines for PCI no longer state that ULM PCI is contraindicated in patients with anatomic conditions that are associated with a low risk of procedural complications and clinical conditions that predict an increased risk of adverse surgical outcomes. ULM PCI should be performed by operators with experience in the management of the anatomic complexities of left main and multivessel disease, specifically in issues relating to bifurcation disease, calcification, and hemodynamic support. Patients with ostial or shaft disease have lower risk of restenosis compared with distal bifurcation disease. Drug-eluting stents (DES) should be used whenever possible as they reduce clinical restenosis. Intravascular ultrasound is an integral component of the procedure as it provides accurate assessment of lesion severity and can confirm optimal stent expansion and apposition. Compliance with dual antiplatelet therapy for at least 12 months is essential if DES are used. A collaborative, multidisciplinary approach with a "Heart Team" represented by a cardiac surgeon, interventional cardiologist, and non-invasive cardiologist may optimize patient education and objective decision making when obtaining informed consent. Application of clinical and angiographic variables into risk models facilitates appropriate patient selection. Randomized clinical trials will address unanswered issues and help build consensus between cardiology and surgical societies to inform clinical decision making and optimize the outcomes for patients with ULM coronary artery disease.

Dobutamine stress cardiovascular magnetic resonance imaging in patients with peripheral artery disease

Patients with peripheral arterial disease often have coronary heart disease, as well. However, their assessment with classical noninvasive cardiology methods is often non-diagnostic or limited. The aim of this study was to analyze the feasibility and the risks of dobutamine stress cardiovascular MRI for cardiac evaluation of patients with peripheral arterial disease. 21 patients with peripheral artery disease (mean±SD age 64.3±7.7 years) were studied prospectively with dobutamine stress cardiovascular MRI. The protocol was completed by all of 21 patients. The target heart rate was attained in 95.2% of the studies. No serious adverse event occurred. The image quality scores (1-4) for all ventricular wall segments were high (median, interquartile range) (4 [4-4]). Five patients (23.8%) have inducible wall motion abnormality. Interobserver agreement was almost perfect for wall motion scores (κ = 0.87, p<0.0001). Dobutamine stress cardiovascular MRI is feasible with low risk for the cardiological assessment of patients with peripheral arterial disease.

Artykuł oryginalny Poziom wiedzy o przewlekłych okluzjach tętnic wieńcowych wśród polskich lekarzy

ENWEndNote BIBJabRef, Mendeley RISPapers, Reference Manager, RefWorks, Zotero AMA Bryniarski L, Zabojszcz M, Bryniarski K, Terlecki M. Original paperKnowledge about chronic total coronary artery occlusions among Polish physicians. Advances in Interventional Cardiology/Postępy w Kardiologii Interwencyjnej. 2010;6(2):66-70. doi:10.5114/pwki.2010.14166. APA Bryniarski, L., Zabojszcz, M., Bryniarski, K., & Terlecki, M. (2010). Original paperKnowledge about chronic total coronary artery occlusions among Polish physicians. Advances in Interventional Cardiology/Postępy w Kardiologii Interwencyjnej, 6(2), 66-70. https://doi.org/10.5114/pwki.2010.14166 Chicago Bryniarski, Leszek, Michał Zabojszcz, Krzysztof Bryniarski, and Michał Terlecki. 2010. "Original paperKnowledge about chronic total coronary artery occlusions among Polish physicians". Advances in Interventional Cardiology/Postępy w Kardiologii Interwencyjnej 6 (2): 66-70. doi:10.5114/pwki.2010.14166. Harvard Bryniarski, L., Zabojszcz, M., Bryniarski, K., and Terlecki, M. (2010). Original paperKnowledge about chronic total coronary artery occlusions among Polish physicians. Advances in Interventional Cardiology/Postępy w Kardiologii Interwencyjnej, 6(2), pp.66-70. https://doi.org/10.5114/pwki.2010.14166 MLA Bryniarski, Leszek et al. "Original paperKnowledge about chronic total coronary artery occlusions among Polish physicians." Advances in Interventional Cardiology/Postępy w Kardiologii Interwencyjnej, vol. 6, no. 2, 2010, pp. 66-70. doi:10.5114/pwki.2010.14166. Vancouver Bryniarski L, Zabojszcz M, Bryniarski K, Terlecki M. Original paperKnowledge about chronic total coronary artery occlusions among Polish physicians. Advances in Interventional Cardiology/Postępy w Kardiologii Interwencyjnej. 2010;6(2):66-70. doi:10.5114/pwki.2010.14166.

A young soldier with syncope, shortness of breath and palpitations

Coronary artery disease in people under 30 years is relatively uncommon, but once a disease occurs it brings a significant morbidity and psychological effects. We reported a 28-year-old patient presenting atypical symptoms after sincopa and non-specific changes on electrocardiogram at admission. After noninvasive and invasive cardiology diagnostic procedures were made, we concluded that he had a subtotal tubular stenosis in proximal segment of the left anterior descending coronary artery. Myocardial revascularization was successfully performed 24-hour after coronarography with the left internal mammary thoracic artery graft on the left anterior descending coronary artery and the patient had a prompt and satisfactory postoperative recovery. This case indicates the importance of a careful evaluation of young adults even if they do not experience typical anginal symptoms or do not have multiple risk factors for cardiovascular diseases.

Letter by Galderisi and Esposito Regarding Article, “Tissue Doppler Imaging in the Estimation of Intracardiac Filling Pressure in Decompensated Patients With Advanced Systolic Heart Failure”

To the Editor: We read with worry the article by Mullens et al1 with regard to the inaccuracy of tissue Doppler in estimating left ventricular (LV) filling pressure in advanced heart failure. Is the dream of noninvasive cardiologists truly disappearing? In our opinion, a critical analysis of this article is needed. The first criticism corresponds to the selected population, which included heterogeneous subsets of patients with advanced heart failure. In particular, cardiac resynchronization therapy represents an important confounding factor by influencing both LV filling and pulsed tissue Doppler in an unpredictable manner. The ratio of early transmitral velocity to tissue Doppler mitral annular early …

Fractional flow reserve: a review

Coronary angiography remains far and away the most accurate morphologic assessment of the lumen of the epicardial coronary arteries. Although non-invasive imaging is rapidly advancing, the temporal and spatial resolution...

Determinants of the degree of functional aortic regurgitation in patients with anatomically normal aortic valve and ascending thoracic aorta aneurysm. Transoesophageal Doppler echocardiography study

Objectives: To identify functional aortic regurgitation (FAR) determinants in patients with ascending thoracic aortic aneurysm (ATAA) and surgically confirmed normal aortic valve anatomy. Design: Case–control study. Setting: Non-invasive Cardiology and...

How compliant are we with guidelines for coronary angiography in clinical practice?

The American College of Cardiology and American Heart Association have published guidelines for coronary angiography. We evaluated the compliance rate with these guidelines in clinical practice, its correlation to results of angiography and aimed to identify problem areas of non-compliance. We prospectively evaluated 802 consecutive referrals for coronary angiography over 5 months in 2002 in a tertiary referral hospital. These referrals were assessed by two independent reviewers blinded to the results of angiography. Patient age was 62 +/- 11 years (522 men, 433 inpatients, 369 day-only patients). Referrals were outside published guidelines in 34.3 and 36.2% as evaluated by the two reviewers (concordance rate 88.2%, kappa = 0.74, p < 0.001). Intraobserver agreement was 97.5%. The rate of angiography showing either normal arteries or only minor diseases (<50%) was higher for referrals outside guidelines (68.4 vs 22.6%, P < 0.001). Compliance rate was high with indications of non-ST-elevation myocardial infarction (99.2%) and ST-elevation myocardial infarction (95.8%), valvular disease (80%) and arrhythmia (80%). Compliance rate was lower with assessment of dyspnoea or heart failure (74.3%) and before non-cardiac surgery (72.7%) and was particularly low with assessment of chest pain (53.2%). Younger age (odds ratio (OR) 1.04, P < 0.001), female sex (OR 2.67, P < 0.001), day-only procedure (OR 2.27, P < 0.001) and non-invasive cardiologist referrer (OR 1.41, P = 0.046) were independent predictors of non-compliance. Referrals for coronary angiography were outside guidelines in a significant proportion of patients. Rate of negative angiography was higher when the referrals were outside guidelines. Problematic areas of non-compliance could be identified. Measures specifically targeting these areas may be more effective in improving the overall guideline compliance in clinical practice.

Real-time three-dimensional echocardiography: a pilot feasibility study in an Italian cardiologic center

The majority of studies demonstrating the diagnostic potential of three-dimensional (3-D) echocardiography have been conducted on selected series of patients in research laboratories. To investigate the feasibility and usefulness of real-time 3-D transthoracic echocardiography in daily routine practice. Two hundred consecutive patients underwent standard two-dimensional (2-D) transthoracic echocardiography (TTE) and real-time (RT) 3-D TTE with a commercially available ultrasound system (Sonos 7500 LIVE 3D, Philips Medical Systems). The quality of 3-D acquisitions and post-processed images was graded as: bad, satisfactory, good and demo. In each case, the results of 3-D TTE were compared with 2-D images to disclose additional qualitative information provided by 3-D examination. An additional qualitative information score was given for each cardiac structure. The mean time of the 3-D examination was 11+/-4 min. The mean time of 2-D transthoracic studies in our laboratory is 25 min and the total time in this series was therefore approximately 36 min. The mean number of acquisitions in our series was 11.5 per patient. The quality was evaluated as bad/insufficient in 7.0%, satisfactory/sufficient in 29.6%, good in 40.2% and demo in 23.2% of all datasets and reconstructions. The structures with greater additional qualitative information scores comprise the anterior and posterior mitralic leaflets, antero-lateral and postero-medial papillary muscles and leaflets of tricuspid valve. The intra- and interobserver reproducibility of quality grading was good and there are few interobserver discrepancies, which were resolved by two physicians, experienced in 3-D echocardiography, not involved in the study. RT 3-D TTE may be used in clinical settings with high feasibility rate and may provide additional, clinically quite relevant qualitative information. This technique may expand the abilities of non-invasive cardiology and open new doors for the evaluation of cardiac disease.

Real-time three-dimensional echocardiography: technological gadget or clinical tool?

The complex anatomy of cardiac structures requires three-dimensional spatial orientation of images for a better understanding of structure and function, thereby improving image interpretation. Real-time three-dimensional echocardiography is a recently developed technique based on the design of an ultrasound transducer with a matrix array that rapidly acquires image data in a pyramidal volume. The simultaneous display of multiple tomographic images allows three-dimensional perspective and the anatomically correct examination of any structure within the volumetric image. As a consequence, it is less operator-dependent and hence more reproducible. Dedicated software systems and technologies are based on high-performance computers designed for graphic handling of three-dimensional images by providing possibilities beyond those obtainable with echocardiography. This methodology allows simultaneous display of multiple superimposed planes in an interactive manner as well as a quantitative assessment of cardiac volumes and ventricular mass in a three-dimensional format without a pre-established assumption of cardiac chamber geometry. In addition, myocardial contraction and/or perfusion abnormalities are clearly identified. Finally, real-time three-dimensional colour Doppler flow mapping enables complete visualisation of the regurgitant jet and new ways of assessing regurgitant lesion severity. Thus, this technique expands the abilities of non-invasive cardiology and may open new doors for the evaluation of cardiac diseases. In this article, current and future clinical applications of real-time three-dimensional echocardiography are reviewed.

631 Comparison of 2DTEE vs 3DTTE in identification of individual scallop prolapse of the mitral valve

1 ; A. Margonato 1 1 San Raffaele Hospital, IRCCS, Division of Non-Invasive Cardiology, Milan, Italy Background: In patients with mitral regurgitation (MR), valve repair is a ma- jor incentive to early surgery and is decided on the basis of the mechanisms and anatomic mitral lesions. These lesions can be easily studied with transesophageal echocardiography (TEE). A study protocol of real-time 3D echocardiography (RT3D) for the identifications of the valve defect is not well validated. Objectives: This study was performed to validate a protocol of RT3D for assessment mitral valve for identification of anatomic valve defect due to prolapse or flail using TEE as gold standard. Methods: One hundred and nineteen consecutive patients with moderate to severe MR (mean age 64±3.4) were studied with RT3D and TEE to iden- tify the valve defects causing MR and the results were evaluated in blind manner. RT3D study protocol was performed as follows: data were acquired in a zoom mode and in a full-volume mode from apical window. Then, using 3D Qlab software (version 2.0, Philips), a volume rendered en-face view of the mitral valve from the left atrium was reconstructed and guided by this view, a series of longitudinal cutplanes were reconstructed to visualise A1- P1, A2-P2 and A3-P3. Segmental analysis of the valve was evaluated accord- ing to American Society of Echocardiography guidelines. Results: Among 119 patients, 66 had prolapse or flail by TEE. The accuracy of RT3D for prolapse lesion was 97% (p=0.0001), with a sensitivity and speci- ficity of 95% and 96% , whereas for flail lesion the accuracy was 95% (p=0.0001) with a sensitivity and specificity of 91% and 97%. The diagnostic accuracy for the individual scallops is reported in Table 1. Conclusions: RT3D protocol using rendered en-face view and a series of longitudinal cutplanes is highly accurate in the identification of anatomic valve defect and its location, particularly showing high specificity values. Table 1 Defect location Aggreement P value Sensitivity Specificity A1 91% (109/119) 0.0001 90% 96% A2 96% (115/119) 0.0001 97% 96% A3 95% (113/119) 0.0001 94% 95% P1 90% (108/119) 0.0001 89% 98% P2 97% (116/119) 0.0001 98% 93% P3 96% (114/119) 0.0001 94% 96%