Real-time 3D Echocardiography Research Articles

0523: Feasibility and accuracy of left ventricular volumes and ejection fraction measured by different echocardiographic methods in congenital heart diseases involving the right ventricle

In CHD with RV volumetric or barometric overload, LV shape is altered. Little is known about the accuracy in this population of left ventricular (LV) volumes and ejection fraction (EF) measurement by standard echocardiographic methods using geometrical assumption: Teicholz, biplane Simpson and real-time 3D echocardiography (RT-3DE). Three-dimensional knowledge-based reconstruction (3D-KR) derived from two-dimensional echocardiographic imaging is a novel technique that has no geometrical assumption. The aim of our study is to assess the accuracy of several echocardiographic methods for measuring LV volumes and EF compared to cardiac magnetic resonance (CMR) measurements (gold standard) in this population. 68 patients (mean age 13,3±4 years) with Congenital Heart Diseases (CHD) involving the RV and referred for cardiac MRI, were included. Among them, 13 patients had barometric overload, 37 patients had volumetric overload, and 18 patients had mixed overload. Echocardiographic images acquisition was performed using a standard ultrasound scanner linked to a Ventripoint Medical Systems unit. Analyzed parameters were end-diastolic volume (EDV), end-systolic volume (ESV), and LVEF measured by Teicholz, Simpson’s modified formula and RT-3DE (GE Vingmed QVG Auto-4D). The method of disks was used for CMR LV volumes. Intra-observer, inter-observer, and inter-technique variability was assessed using intraclass correlation coefficient (CC), Pearson’s CC, coefficients of variation, and Bland-Altman analysis. Feasibility was 98% for Teicholz Method and 3D-KR, 71% for Simpson’s modified formula, and 73% for RT-3DE. We found globally poor correlation and agreement for volumes and EF between the different methods and MRI. The agreement was better when RV volumes were lower than 120 ml/m2 (and thus, LV shape was less altered). LV volumes and EFs cannot be measured accurately by echocardiography in patients with dilated right ventricles.

Real Time 3-D Echocardiography for Evaluation of Left Ventricle in Children

Background: Cardiovascular events and complications are the leading causes of mortality and morbidity in patients with sickle cell anemia (SCA) . Early identification of ventricular dysfunction, before the appearance of symptoms, can alter the prognosis by optimizing therapy. This study aimed at clarifying the value of Real Time 3D Echocardiography (RT3DE ) in early detection of regional myocardial dysfunction in those patients before the development of overt cardiomyopathy. Methods: This is an observational cross sectional study that was carried out on 60 children divided into 2 groups; Group 1 included 30 children with SCA, Group 2: 30 children matched for age and sex as a control group. For all children: ethically committee approval and informed consent from the parents or their guardians was obtained. All Children with SCA under the age of 15 who do not show any signs or symptoms of heart failure were included in this study . Any child with present or past history of heart failure or any child with associated congenital or acquired heart diseases was excluded from the study. All children with systemic diseases that may affect cardiac structure and function have been also excluded. All the children were subjected to through clinical evaluation for any signs of heart failure, Echocardiography studies , included M mode , Tissue Doppler and 4D echo for assessment of left ventricle. Statistical analysis : IBM SPSS statistics was used for data analysis. Data were expressed as Mean ±SD. t test was used for differences in the variables between patients and control . Pearson correlation test was used for possible association between each two variables. Statistical significance was defined as a p value < 0.05. Results: TDI showed left ventricular systolic and diastolic dysfunction in SCA compared with the control. RT3DE was a sensitive tool to detect an increase in LVEF . There was no significant LV enlargement through LV LSS and DSI in our cohort. There was no significant relation between hemoglobin level and different echo parameters in the studied groups. Conclusion : RT3DE with tissue Doppler technique are promising tools for early detection of regional systolic or diastolic dysfunction of left ventricle in children with SCA.

Evaluation of left atrial function by real-time 3-D echocardiography in patients with systemic lupus erythematosus.

Left atrial function plays a key role in maintaining an optimal cardiac output. Left ventricular diastolic dysfunction has been reported in systemic lupus erythematosus (SLE), but its effect on left atrial function has been largely overlooked. Our aim was to assess left atrial performance using real-time 3-D echocardiography (RT3DE) technology in patients with SLE. Our study included 102 patients with SLE without any cardiac symptoms, and 32 healthy controls. According to the Systemic Lupus International Collaborating Clinics/American College of Rheumatology Damage Index (SDI), all subjects were classified into 3 groups: healthy controls, patients with an SDI = 0, and patients with an SDI ≥ 1. Left atrial volume indexed to body surface area was dilated in subjects with SLE, whereas the left atrial passive emptying fraction (EF) was lower. Left atrial active EF was significantly higher in the SDI = 0 group than in controls (46.4 ± 9.1% vs 30.0 ± 10.3%, p < 0.05); however, it was significantly lower in the SDI ≥ 1 group than in the SDI = 0 group (41.2 ± 9.8% vs 46.4 ± 9.1%, p < 0.05). By multivariate linear analysis, the SDI was independently and positively associated with left atrial volume index and inversely associated with left atrial total function. Our study demonstrated that left atrial mechanical function and volume are impaired in SLE, particularly in patients with an SDI ≥ 1 and disease activity. RT3DE may have better diagnostic value than traditional echo indexes in detecting subclinical cardiac dysfunction in patients with SLE.

Assessment of the developmental change in the left atrial volume using real time three-dimensional echocardiography.

Real time 3D echocardiography (RT3DE) has been applied for the assessment of left atrial (LA) function in patients with adult heart disease; however, LA function is not well known in children. We aimed at determining the normal range of LA volume (LAV) using RT3DE and the feasibility and reproducibility of this method in healthy subjects and at elucidating the developmental changes in the LAV with aging. In this study, 359 healthy people (mean age, 23.9 ± 21.3; range, 0.1-76.4 years) were enrolled. We performed transthoracic RT3DE and measured the maximum and minimum LAV. Simultaneously, we measured the LAV using the 2D biplane Simpson's method. Inter-observer and intra-observer variability and the agreement of LAV measurements between RT3DE and 2DE were assessed in a subset of subjects. The RT3DE feasibility for LAV measurement was 93%. Both maximum and minimum LAVs exponentially increased with age and linearly increased with increasing of body surface area (BSA). The LA distensibility, which demonstrates LA reservoir function, decreased with age and BSA. The LAVs measured by RT3DE were significantly smaller than those measured by the 2D biplane Simpson's method. The 3D volumetric method had favorable intra-observer and inter-observer agreement. The reference values of LAV from early infancy to adulthood were obtained using RT3DE, which could be useful for future studies in children with congenital heart disease. RT3DE is a reproducible method and a feasible tool for evaluating the LAV in children. LA reservoir function is likely to decrease with age and increasing of body size.

EComment. Re: a pilot study of systolic dyssynchrony index by real-time three-dimensional echocardiography predicting clinical outcomes to surgical ventricular reconstruction in patients with left ventricular aneurysm.

OBJECTIVES: The aim of the study was to detect whether the systolic dyssynchrony index (SDI) assessed by real-time 3D echocardiography (RT3DE) could predict clinical outcomes of patients with ventricular aneurysm in response to surgical ventricular reconstruction (SVR). METHODS: In total, 120 individuals underwent RT3DE, including 30 healthy volunteers and 90 patients with ventricular aneurysm. All patients underwent clinical and echocardiographic assessments at baseline and at 12 months after SVR. The SDI was defined as the SD of time to minimum systolic volume of the 16 left ventricular (LV) segments, expressed in percent RR duration. SVR responder was defined as a >15% decrease in LV end-systolic volume, reduction in NYHA functional class or 20% relative increase in the LV ejection fraction (LVEF). RESULTS :T he SDI was significantly higher in patients with aneurysm, at 14.3% compared with 2.0% in healthy volunteers (P<0.047). The SDI was negatively correlated with the LVEF. After SVR, 86 patients were responders. In this patient subgroup, the SDI exhibited an immediate significant decrease (to 7.7%; P<0.034) and a progressive decrease during 12 months of follow-up (to 4.9%; P<0.044). The SDI can discriminate SVR responders. Receiver-operating characteristic curve analysis yielded cut-off values of SDI 14.3% best associated with SVR response; area under the curve was 0.79 with reduction in NYHA class, 0.86 with increase in EF and 0.66 with decrease in the end-systolic volume. CONCLUSIONS: RT3DE can be used to assess LV mechanical dyssynchrony in patients with aneurysm. SVR produces a mechanical intraventricular resynchronization and SDI can predict improvement following SVR.

Challenge on Endocardial Three-dimensional Ultrasound Segmentation (CETUS)

Real-time 3D echocardiography has already been shown to be an accurate tool for left ventricular (LV) volume assessment. However, LV border identification remains a challenging task, mainly because of the low contrast of the images combined with drop-out artifacts. Many (semi-)automatic algorithms have been proposed to segment the LV border, but a systematic and fair comparison between such methods has so far been impossible due to a lack of publicly available common database. The aim of this MICCAI challenge was to gather researchers around the field of LV segmentation in 3D cardiac ultrasound by providing a common database to compare algorithms directly. The proposed platform will allow a consistent evaluation and ranking of the current state-of-the-art segmentation solutions and will contribute to a faster clinical translation of groundbreaking technical advances. The purpose of this paper is to describe the technical aspects of the generation of the database, give an overview of the ranking strategy and the outline of the challenge itself.

A pilot study of systolic dyssynchrony index by real-time three-dimensional echocardiography predicting clinical outcomes to surgical ventricular reconstruction in patients with left ventricular aneurysm.

The aim of the study was to detect whether the systolic dyssynchrony index (SDI) assessed by real-time 3D echocardiography (RT3DE) could predict clinical outcomes of patients with ventricular aneurysm in response to surgical ventricular reconstruction (SVR). In total, 120 individuals underwent RT3DE, including 30 healthy volunteers and 90 patients with ventricular aneurysm. All patients underwent clinical and echocardiographic assessments at baseline and at 12 months after SVR. The SDI was defined as the SD of time to minimum systolic volume of the 16 left ventricular (LV) segments, expressed in percent RR duration. SVR responder was defined as a >15% decrease in LV end-systolic volume, reduction in NYHA functional class or 20% relative increase in the LV ejection fraction (LVEF). The SDI was significantly higher in patients with aneurysm, at 14.3% compared with 2.0% in healthy volunteers (P <0.047). The SDI was negatively correlated with the LVEF. After SVR, 86 patients were responders. In this patient subgroup, the SDI exhibited an immediate significant decrease (to 7.7%; P <0.034) and a progressive decrease during 12 months of follow-up (to 4.9%; P <0.044). The SDI can discriminate SVR responders. Receiver-operating characteristic curve analysis yielded cut-off values of SDI 14.3% best associated with SVR response; area under the curve was 0.79 with reduction in NYHA class, 0.86 with increase in EF and 0.66 with decrease in the end-systolic volume. RT3DE can be used to assess LV mechanical dyssynchrony in patients with aneurysm. SVR produces a mechanical intraventricular resynchronization and SDI can predict improvement following SVR.

Assessment of LV ejection fraction using real-time 3D echocardiography in daily practice: direct comparison of the volumetric and speckle tracking methodologies to CMR.

AimsThis study is the first to directly compare two widely used real-time 3D echocardiography (RT3DE) methods of cardiac magnetic resonance imaging (CMR) and assess their reproducibility in experienced and less experienced observers.MethodsConsecutive patients planned for CMR underwent RT3DE within 8 h of CMR with Philips (volumetric method) and Toshiba Artida (speckle tracking method). Left ventricular ejection fraction (LVEF), left ventricular end-diastolic volume (LVEDV) and end-systolic volume (LVESV) were measured using RT3DE, by four trained observers, and compared with CMR values.ResultsThirty-five patients were included (49.7 ± 15.7 years; 55 % male), 30 (85.7 %) volumetric and 27 (77.1 %) speckle tracking datasets could be analysed. CMR derived LVEDV, LVESV and LVEF were 198 ± 58 ml, 106 ± 53 ml and 49 ± 15 %, respectively. LVEF derived from speckle tracking was accurate and reproducible in all observers (all intra-class correlation coefficients (ICC) > 0.86). LVEF derived from the volumetric method correlated well to CMR in experienced observers (ICC 0.85 and 0.86) but only moderately in less experienced observers (ICC 0.58 and 0.77) and was less reproducible in these observers (ICC = 0.55). Volumes were significantly underestimated compared with CMR (p < 0.001).ConclusionThis study demonstrates that both RT3DE methodologies are sufficiently accurate and reproducible for use in daily practice. However, experience importantly influences the accuracy and reproducibility of the volumetric method, which should be considered when introducing this technique into clinical practice.

Feasibility and accuracy of left ventricular volumes and ejection fraction measured by different echocardiographic methods in congenital heart diseases involving the right ventricle

In CHD with RV volumetric or barometric overload, LV shape is altered. Little is known about the accuracy in this population of left ventricular (LV) volumes and ejection fraction (EF) measurement by standard echocardiographic methods using geometrical assumption: Teicholz, biplane Simpson and real-time 3D echocardiography (RT-3DE). Three-dimensional knowledge-based reconstruction (3D-KR) derived from two-dimensional echocardiographic imaging is a novel technique that has no geometrical assumption. The aim of our study is to assess the accuracy of several echocardiographic methods for measuring LV volumes and EF compared to cardiac magnetic resonance (CMR) measurements (gold standard) in this population. 68 patients (mean age 13,3 ± 4 years) with Congenital Heart Diseases (CHD) involving the RV and referred for cardiac MRI, were included. Among them, 13 patients had barometric overload, 37 patients had volumetric overload, and 18 patients had mixed overload. Echocardiographic images acquisition was performed using a standard ultrasound scanner linked to a Ventripoint Medical Systems unit. Analyzed parameters were end-diastolic volume (EDV), end-systolic volume (ESV), and LVEF measured by Teicholz, Simpson's modified formula and RT-3DE (GE Vingmed QVG Auto-4D). The method of disks was used for CMR LV volumes. Intra-observer, inter-observer, and inter-technique variability was assessed using intraclass correlation coefficient (CC), Pearson's CC, coefficients of variation, and Bland-Altman analysis. Feasibility was 98% for Teicholz Method and 3D-KR, 71% for Simpson's modified formula, and 73% for RT-3DE. We found globally poor correlation and agreement for volumes and EF between the different methods and MRI. The agreement was better when RV volumes were lower than 120 mL/m 2 (and thus, LV shape was less altered). LV volumes and EFs cannot be measured accurately by echocardiography in patients with dilated right ventricles.

3D echocardiography in congenital heart disease: a valuable tool for the surgeon.

Real-time 3D echocardiography has been used increasingly in the assessment of patients with congenital heart disease. A number of studies have confirmed that this modality can be used as a complementary method to delineate morphology and spatial relationships of simple and more complex congenital heart lesions during surgical planning. Communication between the echocardiographer and surgeon can be simplified as simulation of surgical views can be achieved, thus minimizing the potential for error related to mental reconstruction. This review summarizes the available evidence for the role of real-time 3D echocardiography in congenital heart disease as an imaging modality to assist surgeons.

Comprehensive evaluation of cardiac function and detection of myocardial infarction based on a semi-automated analysis using full-volume real time three-dimensional echocardiography.

Quantitative left ventricular mass (LVM) as well as regional strain values may be obtained from full-volume real time 3D echocardiography data via semi-automated feature tracking and represent indices of heart function, both in health and disease. Fresh adult porcine and ovine hearts were passively pumped to simulate normal cardiac motion at stroke volumes (SVs) varying from 30 to 70 mL. A 3V-D Matrix probe, interfaced with a GE Vivid E9 ultrasound system, was used to image each heart at baseline conditions and after simulated myocardial infarction (MI). The 4D LV quantification function of EchoPAC PC was used to quantify the LVM and longitudinal and circumferential strain (LS & CS) of LV segments at each SV prior and subsequent to simulated MI. LVM was validated by volumetric displacement, while LS and CS values were compared to sonomicrometry-based strain. Linear regression analyses show excellent correlations in LVM, LS, and CS between the 4D echo and volumetric/sonomicrometric displacement with R(2) values of 0.99, 0.88, and 0.67, respectively. Bland-Altman analyses for all variables validate the compatibility of both methods. It was also determined that EchoPAC PC was able to detect a decrease in LS and CS in the relevant segments between pre- and post-MI at all SVs (P < 0.05). EchoPAC PC is a robust utility with the ability to accurately obtain quantitative LVM, LS, and CS values from 4D echo volumes and has the potential to improve the yield of clinical studies in cases of suspected MI.

Quantification of Mitral Valve Morphology With Three-Dimensional Echocardiography

The mitral valve (MV) has complex 3-dimensional (3D) morphology and motion. Advance in real-time 3D echocardiography (RT3DE) has revolutionized clinical imaging of the MV by providing clinicians with realistic visualization of the valve. Thus far, RT3DE of the MV structure and dynamics has adopted an approach that depends largely on subjective and qualitative interpretation of the 3D images of the valve, rather than objective and reproducible measurement. RT3DE combined with image-processing computer techniques provides precise segmentation and reliable quantification of the complex 3D morphology and rapid motion of the MV. This new approach to imaging may provide additional quantitative descriptions that are useful in diagnostic and therapeutic decision-making. Quantitative analysis of the MV using RT3DE has increased our understanding of the pathologic mechanism of degenerative, ischemic, functional, and rheumatic MV disease. Most recently, 3D morphologic quantification has entered into clinical use to provide more accurate diagnosis of MV disease and for planning surgery and transcatheter interventions. Current limitations of this quantitative approach to MV imaging include labor-intensiveness during image segmentation and lack of a clear definition of the clinical significance of many of the morphologic parameters. This review summarizes the current development and applications of quantitative analysis of the MV morphology using RT3DE.

Manual of 3D Echocardiography

Three-dimensional (3D) echocardiography has rapidly evolved into a useful imaging modality since its advent on the clinical horizon from the research labs about a decade ago. From primarily being considered as a modality which only offered an improved image quality and did not have any major quantitative possibilities, real time 3D echocardiography has come a long way in a relatively short time span. It has been shown to be reliable, reproducible and accurate. Volumetric analysis has been simplified and shown to be comparable to the current gold standard – cardiac MRI. The objectivity introduced, ease of use, coupled with excellent reproducibility has come as a boon for measuring volumes and LV ejection fraction – one of the most useful prognostic parameter in cardiology. In valvular heart disease, 3D derived planimetry of the mitral valve is the current echocardiographic gold standard in mitral stenosis. The repair revolution in mitral valve regurgitation is driving on due to the views provided by 3D echocardiography. In the cath lab too, the percutaneous interventions like transcatheter aortic valve implantation, Mitra-clip, atrial septal defect closure, paravalvular regurgitation closure are all being facilitated by the unique perspectives provided by real time 3D transesophageal echocardiography. Unfortunately, in spite of the obvious advantages offered by the technique, its use has not spread in the country to the extent possible. The physicians, accustomed over the years to viewing the two-dimensional (2D) images, seem intimidated by the new technique and its nuances. This is partly because of lack of good quality texts dealing with the subject and its application in day to day clinical practice. There has thus been a felt need among the echocardiographers to understand this new modality. This is evident in the interest generated and the attendance in the various workshops conducted on 3D echocardiography. This book, “Manual of 3D Echocardiography” put together by Dr V Amuthan and his esteemed colleagues, thus could not have been more aptly timed. An eminent cardiologist of the country, Dr Amuthan is an emeritus professor at the Tamil Nadu MGR Medical University, Chennai. He was formerly the head of the department at Madurai Medical College in Tamil Nadu. He is also the Vice President of the Indian academy of echocardiography. Even at this age, he has tremendous interest in the field of echocardiography, particularly, 3D echocardiography, and is a regular at various conferences and events in cardiology. It came as no surprise therefore, that he thought of taking up this task of writing a manual of 3D echocardiography. The book begins with chapters on the scope of 3D echocardiography and its various modes. There is a description of equipment and the unique features of 3D imaging like slicing and cropping. The book then moves on to explain the role of 3D echo in various clinical conditions with chapters on rheumatic heart disease, coronary artery disease and congenital heart disease with abundant illustrations and references on 3D transthoracic and transesophageal echocardiography. There are separate chapters on 3D TEE guidance in interventions and on device closure of atrial septal defects, a field where 3D TEE is fast becoming indispensable. At the end of the book, there is an atlas of 3D echo images covering some of the common cardiac conditions such as dissection flaps, masses, aortic root abscesses etc. The book is accompanied by 3 DVDs containing video recordings of the lectures on 3D echocardiography and workshops demonstrating the use of 3D echocardiography in cardiac interventions such as balloon mitral valvotomy. However, there were just a few points which we found worth mentioning. The images in the atlas are not labelled, which makes it somewhat difficult for a beginner to identify the lesions. In addition, a mention of the mode of 3D echo used to obtain these images would have been welcome. In the DVDs, inclusion of 3D clips of various disease states would have been very useful. This would have added to the information needed by the interested readers in understanding the 3D images. All in all, a good beginning for the texts on 3D echocardiography, in our country!

小児におけるリアルタイム3D心エコーを用いた左房解析の有用性

背景：成人領域では左房容積が左室拡張能障害や心不全の予後予測因子として認識され，3Dエコーを用いた左房計測が広まりつつある．目的：小児におけるリアルタイム3D心エコーを用いた左房解析の有用性を検討する．対象と方法：心内形態異常を伴わない小児52例（男児23例，平均年齢5.4±3.7歳）を対象とし，Philips社iE33を用いて3D四腔断面像を記録，QLAB（ver7）を用いて左房容積を計測し，さらに同3D画像から四腔・二腔断面を切り出しModified-Simpson（MS）法，Area-Length（AL）法で左房容積を計測，撮像した2D画像からもMS法，AL法で左房容積を計測して比較検討した．結果：記録時の平均心拍数は90±22 bpm，平均フレームレートは28±7 Hzであった．最大左房容積係数LAVI（Left atrium volume/BSA）は平均17.6±3.7 mL/m2，最小LAVIは平均5.9±1.5 mL/m2，平均EF 66.3±5.2％であり，性別・年齢による有意差はなかった．測定誤差は検者内：最大LAVI －1.3±3.0 mL/m2（平均差±Limits of agreement），最小LAVI －1.0±2.2 mL/m2，検者間：0.5±5.2 mL/m2，－0.4±2.8 mL/m2と再現性は良好であった．3D画像によるMS法とAL法では最大LAVIがそれぞれ16.2±3.1 mL/m2（1.0±4.4），18.2±3.8 mL/m2（－0.5±5.4）でほぼ一致していた．2D画像からの計測は左房長軸の描出に劣るため測定誤差－3.3±7.0 mL/m2，－3.3±6.6 mL/m2とやや過大評価であった．まとめ：3Dエコーによる左房解析は小児においても有用であった．今後は計測値の蓄積により小児における正常値を求めることが期待される．

Comprehensive understanding of atrial septal defects by imaging studies for successful transcatheter closure.

Transcatheter closure of atrial septal defects has become a popular procedure. The availability of a preprocedural imaging study is crucial for a safe and successful closure. Both the anatomy and morphology of the defect should be precisely evaluated before the procedure. Three-dimensional (3D) echocardiography and cardiac computed tomography are helpful for understanding the morphology of a defect, which is important because different defect morphologies could variously impact the results. During the procedure, real-time 3D echocardiography can be used to guide an accurate closure. The safety and efficiency of transcatheter closures of atrial septal defects could be improved through the use of detailed imaging studies.

Three-Dimensional Echocardiography: Advancements in Qualitative and Quantitative Analyses of Mitral Valve Morphology in Mitral Valve Prolapse.

Degenerative mitral valve disease (MVD) is the leading cause of organic mitral regurgitation (MR), one of the most common valvular heart disease in western countries. Substantial progresses in the surgical treatment of degenerative MVD have improved life expectancy of patients with significant MR. However, prognosis, surgical decision and timing of surgery strongly depend on the accurate characterization of mitral valve (MV) anatomy and pathology and on the precise quantification of MR. Three-dimensional (3D) echocardiography, a major technological breakthrough in the field of cardiovascular imaging, provides several advantages over two-dimensional (2D) imaging in the qualitative and quantitative evaluations of MV apparatus. In this review, we focus on the contribution of this new modality to the diagnosis of degenerative MVD, the quantitative assessment of MR severity, the selection and monitoring of surgical and percutaneous procedures, the evaluation of procedural outcomes. The results of a systematic and exhaustive search of the existing literature, restricted to real-time 3D echocardiography in adults, are here reported.

Two‐dimensional speckle tracking echocardiography combined with high‐sensitive cardiac troponin T in early detection and prediction of cardiotoxicity during epirubicine‐based chemotherapy

To investigate whether alterations of myocardial strain and high-sensitive cardiac troponin T (cTnT) could predict future cardiac dysfunction in patients after epirubicin exposure. Seventy-five patients with non-Hodgkin lymphoma treated with epirubicin were studied. Blood collection and echocardiography were performed at baseline, 1 day after the third cycle, and 1 day after completion of chemotherapy. Patients were studied using echocardiography during follow-up. Global longitudinal (GLS), circumferential (GCS), and radial strain (GRS) were calculated using speckle tracking echocardiography. Left ventricular ejection fraction was analysed by real-time 3D echocardiography. Cardiotoxicity was defined as a reduction of the LVEF of ≥5% to <55% with symptoms of heart failure or an asymptomatic reduction of the LVEF of ≥10% to <55%. Fourteen patients (18.67%) developed cardiotoxicity after treatment. GLS (-18.48 ± 1.72% vs. -15.96 ± 1.6%), GCS (-20.93 ± 2.86% vs. -19.20 ± 3.21%), and GRS (39.23 ± 6.44% vs. 34.98 ± 6.2%) were markedly reduced and cTnT was elevated from 0.0010 ± 0.0020 to 0.0073 ± 0.0038 ng/mL (P all < 0.01) at the completion of chemotherapy compared with baseline values. A >15.9% decrease in GLS [sensitivity, 86%; specificity, 75%; area under the curve (AUC) = 0.815; P = 0.001] and a >0.004 ng/mL elevation in cTnT (sensitivity, 79%; specificity, 64%; AUC = 0.757; P = 0.005) from baseline to the third cycle of chemotherapy predicted later cardiotoxicity. The decrease in GLS remained the only independent predictor of cardiotoxicity (P = 0.000). GLS combined with cTnT may provide a reliable and non-invasive method to predict cardiac dysfunction in patients receiving anthracycline-based chemotherapy.

Nonsymmetric Myocardial Contribution to Supranormal Right Ventricular Function in the Athlete's Heart: Combined Assessment by Speckle Tracking and Real Time Three‐Dimensional Echocardiography

To investigate determinants of right ventricular (RV) function in competitive athletes by a combined assessment of speckle tracking (STE) and real time 3D echocardiography (RT3DE). Right ventricular function of 40 top-level rowers was compared to 43 sedentary normal controls by standard Doppler echocardiography, RT3DE, and STE. RV diameters and wall thickness, tricuspid annular plane systolic excursion (TAPSE), tricuspid E/A ratio, and pulsed tissue Doppler of lateral tricuspid annulus were analyzed. RV volumes, ejection fraction (EF), and stroke volume (SV) were determined. RV global longitudinal strain (GLS) (average of 6 regions), septal strain (average of 3 septal regions, septal longitudinal strain [SLS]), and lateral strain (average of 3 lateral regions, lateral longitudinal strain [LLS]) were estimated by STE. The 2 groups were comparable for age, body mass index, and blood pressure, but heart rate was lower in rowers. RV diameters were larger and TAPSE, tricuspid E/A ratio, and tissue Doppler-derived s' and e' velocities were higher in rowers. By RT3DE, RV end-diastolic volume (EDV) and end-systolic volume were greater in rowers (both P<0.0001), without difference in EF. GLS (P<0.005) and LLS (P<0.001), but not SLS, were greater in rowers. In pooled groups, LLS was related to EDV and SV, even after adjusting for heart rate, body mass index, and RV wall thickness by separate multiple linear regression analyses (β coefficient=0.247, P<0.01 and β=0.225, P<0.02, respectively). Right ventricular preload exerts its maximal influence on the longitudinal lateral fibers, which is independent on potential confounders and largely induces RV supranormal function in the athlete's heart.

Spatiotemporal Accuracy of Real-Time 3D Echocardiography in the Neonatal and Pediatric Setting – Validation Studies using Small Dynamic Test Objects

The precision of real-time 3D-echocardiography (RT3DE) is not sufficiently validated for small, fast-moving structures such as the neonatal and pediatric heart. To assess the spatiotemporal accuracy of RT3DE in small, moving test objects. Small, calibrated test objects in the size of neonatal and pediatric heart chambers were made from polyurethane foam or metal wire mesh and moved in a water bath through a calibrated dynamic test system. Using matrix transducers (X7-2, ie33 and X4-1, Sonos 7500, Philips, Andover, USA), 2 D and live 3 D datasets under variation of the motion speed (0.033 - 0.133 m/s corresponding to 50 - 200 heart cycles/minute), the volume rate and transducer position were recorded and analyzed (QLab 7.0, Philips). 3 D datasets of the moving test objects showed relevant spatial distortion, which was obviously related to the sequential scanning technology of the matrix transducer. Different segments of a test object were not recorded simultaneously, but rather row-by-row, so that there was a time delay between the first and the last-recorded voxel of a single 3 D volume (mean±SD: 28.9 ± 7.82 m/s or 80 ± 7 % of the time duration of a 3 D volume). With increasing motion speed of the test object and reduced 3 D volume rate, the distortion artifacts increased significantly. 3 D acquisitions using matrix technology demonstrate relevant spatiotemporal inaccuracies. This may lead to misinterpretations during the evaluation of the synchronicity of valvular or ventricular motion and incorrect definition of volume estimations. In particular, at higher heart rates and higher rates of movement, these limitations have to be taken into account in clinical practice.

Catheter-Based Endomyocardial Delivery of Mesenchymal Precursor Cells Using 3D Echo Guidance Improves Cardiac Function in a Chronic Myocardial Injury Ovine Model

The administration of bone marrow-derived stem cells may provide a new treatment option for patients with heart failure. Transcatheter cell injection may require multi-imaging modalities to optimize delivery. This study sought to evaluate whether endomyocardial injection of mesenchymal precursor cells (MPCs) could be guided by real-time 3D echocardiography (RT3DE) in treating chronic, postinfarction (MI) left ventricular (LV) dysfunction in sheep. Four weeks after induction of an anterior wall myocardial infarction in 39 sheep, allogeneic MPCs in doses of either 25 × 10(6) (n = 10), 75 × 10(6) (n = 9), or 225 × 10(6) (n = 10) cells or nonconditioned control media (n = 10) were administered intramyocardially into infarct and border zone areas using a catheter designed for combined fluoroscopic and RT3DE-guided injections. LV function was assessed before and after injection. Infarct dimension and vascular density were evaluated histologically. RT3DE-guided injection procedures were safe. Compared to controls, the highest dose MPC treatment led to increments in ejection fraction (3 ventricula 3% in 225M MPCs vs. -5 ± 4% in the control group, p < 0.01) and wall thickening in both infarct (4 ± 4% in 225M MPCs vs. -3 ± 6% in the control group, p = 0.02) and border zones (4 ± 6% in 225M MPCs vs. -8 ± 9% in the control group, p = 0.01). Histology analysis demonstrated significantly higher arteriole density in the infarct and border zones in the highest dose MPC-treated animals compared to the lower dose or control groups. Endomyocardial implantation of MPCs under RT3DE guidance was safe and without observed logistical obstacles. Significant increases in LV performance (ejection fraction and wall thickening) and neovascularization resulted from this technique, and so this technique has important implications for treating patients with postischemic LV dysfunction.